BCA’s Favorite Diagnosis Codes A Work-in-Progress

Table of Contents:

ICD-10-CM Section IV Guidelines 2-Page Insert Diabetes Type 2 Page 1 Diabetes Type 1 Page 2 Cardiac Conditions Page 3 Hypertension & Hypertensive Heart & Kidney Disease Page 4 COPD/Asthma/Bronchitis Page 5 Weight Management Page 6 Pregnancy Page 7 Family Planning & STI’s Pages 8 - 9 Pediatrics Pages 10 - 11 Prevention Pages 12 - 13 Acute Illness Pages 14 - 15 Fractures/Injuries/Burns Pages 16 - 17 Psychiatric & Related Diagnosis Pages 18 - 20 Chronic Pain and Substance Abuse Pages 21 - 23 Social Determinates Pages 13 & 20

© Brown Consulting Associates, Inc. - www.codinghelp.com - Last updated March 6, 2019 ICD‐10‐CM Official Guidelines, Effective October 1, 2018 [Required/HIPAA Legislation] Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital‐based outpatient services and provider‐based office visits. Guidelines in Section I, Conventions, general coding guidelines and chapter‐specific guidelines, should also be applied for outpatient services and office visits. Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD‐10‐CM Tabular List (code numbers and titles), can be found in Section IA of these guidelines, under “Conventions Used in the Tabular List.” Section I.B. contains general guidelines that apply to the entire classification. Section I.C. contains chapter‐specific guidelines that correspond to the chapters as they are arranged in the classification. Information about the correct sequence to use in finding a code is also described in Section I. The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other. Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that: The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to hospital‐based outpatient services and provider‐based office visits. Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. A. Selection of first‐listed condition In the outpatient setting, the term first‐listed diagnosis is used in lieu of principal diagnosis. In determining the first‐listed diagnosis the coding conventions of ICD‐10‐CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors. 1. Outpatient Surgery: When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first‐listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. 2. Observation Stay: When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first‐listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. B. Codes from A00.0 through T88.9, Z00‐Z99 The appropriate code(s) from A00.0 through T88.9, Z00‐Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. C. Accurate reporting of ICD‐10‐CM diagnosis codes For accurate reporting of ICD‐10‐CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD‐10‐CM codes to describe all of these. D. Codes that describe symptoms and signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD‐10‐CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00‐R99) contain many, but not all codes for symptoms. E. Encounters for circumstances other than a disease or injury ICD‐10‐CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00‐Z99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems. See Section I.C.21. Factors influencing health status and contact with health services. F. Level of Detail in Coding 1. ICD‐10‐CM codes with 3, 4, 5, 6 or 7 characters: ICD‐10‐CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD‐10‐CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. 2. Use of full number of characters required for a code: A three‐character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including t he 7th character, if applicable. G. ICD‐10‐CM code for the diagnosis, condition, problem, or other reason for encounter/visit: List first the ICD‐10‐CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first‐listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. H. Uncertain diagnosis: Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short‐term, acute care, long‐term care and psychiatric hospitals. I. Chronic diseases: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) J. Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80‐ Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. K. Patients receiving diagnostic services only For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non‐ routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results. L. Patients receiving therapeutic services only For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, the diagnosis or problem for which the service is being performed listed second. M. Patients receiving preoperative evaluations only For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre‐procedural examinations, to describe the pre‐op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre‐op evaluation. N. Ambulatory surgery For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive. O. Routine outpatient prenatal visits See Section I.C.15. Routine outpatient prenatal visits. P. Encounters for general medical examinations with abnormal findings The subcategories for encounters for general medical examinations, Z00.0‐ and encounter for routine child health examination, Z00.12‐, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first‐listed diagnosis. An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A secondary code for the abnormal finding should also be coded. Q. Encounters for routine health screenings See Section I.C.21. Factors influencing health status and contact with health services, Screening See also Disease Specific Guidelines (e.g., diabetes, HTN etc. in Section A in your ICD‐10 book or on CDC website.

End of HIPPA ICD‐10‐CM Section IV Guidelines DIABETES TYPE 2 DX CODE SHEET (not an all inclusive list, see ICD-10) Type 2 Diabetes without complications Code Also Assign Overweight/Obesity & BMI (adult) Code DM controlled and without complications HCC 19 E11.9 Overweight Code ➔ E66.3 DM uncontrolled w/ hyperglycemia HCC 18 E11.65 BMI range 25.0 - 25.9 (See peds sheet for ped BMIs) ✚Z68.25 DM uncontrolled w/ hypoglycemia, w/o coma HCC 18 E11.649 BMI range 26.0 - 26.9 ✚Z68.26 hypoglycemia, with coma HCC 17 E11.641 BMI range 27.0 - 27.9 ✚Z68.27 Always code for DM2 patient on insulin HCC 19 ✚Z79.4 BMI range 28.0 - 28.9 ✚Z68.28 Long-term use oral hypoglycemic med (not w/ Z79.4) ✚Z79.84 BMI range 29.0 - 29.9 ✚Z68.29 DM with complication of neurological system, specifically; Obesity due to excess calories ➔ E66.09 polyneuropathy HCC 18 E11.42 BMI range 30.0-30.9 Z68.30 BMI range 35.0-35.9 Z68.35 mononeuropathy HCC 18 E11.41 BMI range 31.0-31.9 Z68.31 BMI range 36.0-36.9 Z68.36 gastroparesis (autonomic polyneuropathy) HCC 18 E11.43 BMI range 32.0-32.9 Z68.32 BMI range 37.0-37.9 Z68.37 DM with unspecified neuropathy HCC 18 E11.40 BMI range 33.0-33.9 Z68.33 BMI range 38.0-38.9 Z68.38 DM with neuropathic arthropathy HCC 18 E11.610 BMI range 34.0-34.9 Z68.34 BMI range 39.0-39.9 Z68.39 If the DM is not in control assign also HCC 18 ✚E11.65 Morbid Obesity due to excess calories ➔ HCC 22 E66.01 Diabetes w/complication of circulatory system, specifically; BMI range 40.0 - 44.9 HCC 22 ✚Z68.41 DM with peripheral angiopathy, no gangrene HCC 18 & 108 E11.51 BMI range 45.0 - 49.9 HCC 22 ✚Z68.42 DM w/peripheral angiopathy, w/ gangrene HCC 18, 106 & 108 E11.52 BMI range 50.0 - 59.9 HCC 22 ✚Z68.43 DM with other circulatory complication HCC 18 E11.59 BMI range 60.0 - 69.9 HCC 22 ✚Z68.44 If the DM is not in control assign also HCC 18 ✚E11.65 BMI 70 or greater HCC 22 ✚Z68.45 DM with diabetic nephropathy HCC 18 E11.21 Some Signs/Symptom Codes DM with proteinuria or microalbuminuria: E11.29 and R80.9 Blurry vision H53.8 DM with complication of CKD code also stage HCC 18 E11.22 Excessive thirst R63.1 CKD stage 1 GFR >90 (Glomerular Filtration Rate) ✚N18.1 Excessive eating/appetite R63.2 CKD stage 2 GFR 60-89 (Mild) ✚N18.2 Frequent urination R35.0 CKD stage 3 GFR 30-59 (Moderate) ✚N18.3 Numbness in hands/feet R20.0 CKD stage 4 GFR 15-29 (Severe) HCC 137 ✚N18.4 Polyuria R35.8 CKD stage 5 GFR <15 HCC 136 ✚N18.5 Tingling in hands/feet R20.2 End Stage Renal Disease (ESRD) HCC 136 ✚N18.6 Weight loss R63.4 If the DM is not controlled, assign also HCC 18 ✚E11.65 Status and History Codes DM with complication of eyes, specifically: Amputation, BK: L BK = Z89.512 R BK = HCC 189 Z89.511 DM w/nonproliferative retinopathy w/o edema HCC 18 E11.329- Family history of diabetes Z83.3 with macular edema HCC 18 E11.321- Family history of familial hypercholesterolemia Z83.42 DM w/proliferative retinopathy see choices HCC 18 E11.351- History of tobacco dependence Z87.891 Dash indicates must have 7th character thru E11.359- Special Social Influence Dx Codes DM with diabetic cataract HCC 18 E11.36 Lack of adequate food/safe drinking water Z59.4 DM with eye complication not listed above HCC 18 E11.39 Homelessness Z59.0 If the DM is not in control assign also HCC 18 ✚E11.65 Inadequate housing Z59.1 Diabetes - varied complications Low income Z59.6 DM with; arthropathy HCC 18 E11.618 Extreme poverty Z59.5 dermatitis HCC 18 E11.620 Diabetes in pregnancy not here - see ICD10 Category O24 foot ulcer (Code also site L97.4-, L97.5-) HCC 18 & 161 E11.621 Miscellaneous Diagnoses Code skin ulcer (Code also site L97.1-L98.49) HCC 18 & 161 E11.622 Lab Dx: Impaired fasting glucose R73.01 other skin complication HCC 18 E11.628 Abnormal glucose, prediabetic R73.09 DM with hyperosmolarity, without coma HCC 17 E11.00 Elevated blood sugar R73.9 hyperosmolarity, with coma HCC 17 E11.01 Screening for diabetes mellitus Z13.1 If DM is not in control assign also HCC 18 ✚E11.65 Metabolic syndrome E88.81 Nicotine Dependence, Use, Exposure Pre-diabetes (borderline DM, latent DM) R73.03 Cigarette, uncomplicated (no related illness) F17.210 Lipoid Disorders: Hypercholesterolemia, pure E78.00 in remission F17.211 Familial hypercholesterolemia E78.01 Vapor or "Other" uncomplicated F17.290 Hyperglyceridemia (very low density lipoid type) E78.1 in remission F17.291 Mixed hyperlipidemia (combo of E78.0 & E78.1) E78.2 Chewing tobacco, uncomplicated F17.220 Dislipidemia/hyperlipidemia, unspecified E78.5 in remission F17.221 Noncompliance w/treatment Z91.19 2nd hand tobacco smoke exposure Z77.22 Noncompliance w/renal dialysis HCC 134 Z91.15 Occupational tobacco smoke exposure Z57.31 Underdosing of hypoglycemic med d/t financial hardship T38.3X6X History of tobacco dependence Z87.891 7th character of code, replace "X" with X=A,Dor S Tobacco use, [no dependence] avoid Z72.0 A = initial (active) visit, D = follow-up, S = Sequela & Z91.120

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - November 19, 2018 1 DIABETES TYPE 1 DX CODE SHEET Diabetes without complications Type 1 Miscellaneous Diagnoses Type 1 DM controlled and without complications HCC E10.9 Lab Dx: Impaired fasting glucose R73.01 DM uncontrolled HCC E10.65 Abnormal glucose, not currently diabetic R73.09 Diabetes with complications Type 1 Prediabetes R73.03 DM with complication of neurological system, specifically; Elevated blood sugar R73.9 polyneuropathy HCC E10.42 Screening for diabetes mellitus Z13.1 mononeuropathy HCC E10.41 Lipoid Disorders: Pure hypercholesterolemia E78.00 gastroparesis (autonomic polyneuropathy) HCC E10.43 Familial hypercholesterolemia E78.01 DM with neuropathic arthropathy HCC E10.610 Hyperglyceridemia (very low density lipoid type) E78.1 DM with any other neuro comp. not listed above HCC E10.40 Mixed hyperlipidemia (combo of E78.0 & E78.1) E78.2 If the DM is not in control assign also HCC ✚E10.65 Dislipidemia/hyperlipidemia, unspecified E78.5 Diabetes with complication of circulatory system, specifically; Noncompliance w/treatment Z91.19 DM with peripheral angiopathy, no gangrene HCC E10.51 Noncompliance w/renal dialysis HCC Z91.15 DM with peripheral angiopathy, with gangrene HCC E10.52 Underdosing of hypoglycemic med d/t financial hardship T38.3X6X DM with other circulatory complication HCC E10.59 7th character of code, replace "X" with X=A,Dor S If the DM is not in control assign also HCC ✚E10.65 A = initial (active) visit, D = follow-up, S = Sequala & Z91.120 DM with diabetic nephropathy HCC E10.21 Assign Overweight/Obesity & BMI DM with complication of CKD code also stage HCC E10.22 Overweight Code ➔ E66.3 CKD stage 1 GFR >90 (Glomerular Filtration Rate) ✚N18.1 BMI between 25.0 - 25.9(See pediatric BMIs on Peds sheet) ✚Z68.25 CKD stage 2 GFR 60-89 (Mild) ✚N18.2 BMI between 26.0 - 26.9 ✚Z68.26 CKD stage 3 GFR 30-59 (Moderate) ✚N18.3 BMI between 27.0 - 27.9 ✚Z68.27 CKD stage 4 GFR 15-29 (Severe) HCC ✚N18.4 BMI between 28.0 - 28.9 ✚Z68.28 CKD stage 5 GFR <15 HCC ✚N18.5 BMI between 29.0 - 29.9 ✚Z68.29 End Stage Renal Disease (ESRD) HCC ✚N18.6 Obesity due to excess calories ➔ E66.09 DM with complication of eyes, specifically; Type 1 BMI between 30.0-30.9 Z68.30 BMI between 35.0-35.9 Z68.35 DM w/nonproliferative retinopathy w/o mac. edema HCC E10.329 BMI between 31.0-31.9 Z68.31 BMI between 36.0-36.9 Z68.36 with macular edema HCC E10.321 BMI between 32.0-32.9 Z68.32 BMI between 37.0-37.9 Z68.37 DM w/proliferative retinopathy see choices E11.351X - BMI between 33.0-33.9 Z68.33 BMI between 38.0-38.9 Z68.38 HCC (must have 6th & 7th characters) E11.359X BMI between 34.0-34.9 Z68.34 BMI between 39.0-39.9 Z68.39 DM with diabetic cataract HCC E10.36 Morbid Obesity due to excess calories HCC➔ E66.01 DM with eye complication not listed above HCC E10.39 BMI between 40.0 - 44.9 HCC ✚Z68.41 If the DM is not in control assign also HCC ✚E10.65 BMI between 45.0 - 49.9 HCC ✚Z68.42 Other complications Type 1 BMI between 50.0 - 59.9 HCC ✚Z68.43 DM with; arthropathy HCC E10.618 BMI between 60.0 - 69.9 HCC ✚Z68.44 dermatitis HCC E10.620 BMI 70 or greater HCC ✚Z68.45 foot ulcer (Code also site L97.4-, L97.5-) HCC E10.621 Some Signs/Symptom Codes skin ulcer (Code also site L97.1-L98.49) HCC E10.622 Blurry vision H53.8 other skin complication HCC E10.628 Excessive thirst R63.1 DM with hypoglycemia, without coma HCC E10.649 Excessive eating/appetite R63.2 hypoglycemia, with coma HCC E10.641 Frequent urination R35.0 DM with ketoacidosis, without coma HCC E10.10 Numbness in hands/feet R20.0 ketoacidosis, with coma HCC E10.11 Polyuria R35.8 If DM is not in control assign also HCC ✚E10.65 Tingling in hands/feet R20.2 Nicotine Dependence, Use, Exposure Weight loss R63.4 Cigarette, uncomplicated (no related illness) F17.210 Status and Hx Codes in remission F17.211 Amputation, BK: L BK = Z89.512 R BK = HCC Z89.511 Vapor or "Other" uncomplicated F17.290 Family history of diabetes Z83.3 in remission F17.291 Family history of familial hypercholesterolemia Z83.42 Chewing tobacco, uncomplicated F17.220 History of tobacco dependence Z87.891 in remission F17.221 Special Social Influence Dx Codes - Add to tell your story 2nd hand tobacco smoke exposure Z77.22 Lack of adequate food/safe drinking water Z59.4 Occupational tobacco smoke exposure Z57.31 Homelessness Z59.0 History of tobacco dependence Z87.891 Inadequate housing Z59.1 Tobacco use, [no dependence] avoid Z72.0 Low income Z59.6 Extreme poverty Z59.5 Diabetes in pregnancy not here - see ICD10 Category O24

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 19, 2017 2 NON-HYPERTENSIVE CARDIAC DX CODE SHEET Abnormal Findings Code Conduction/Rhythm Disorders Code Blood pressure reading low (not hypotension - see I95.X) R03.1 Atrial fibrillation, chronic HCC 96 I48.2 Blood pressure, elevated but not HTN R03.0 Atrial fibrillation, paroxysmal HCC 96 I48.0 Cardiovascular function study, (e.g., ABN stress test) R94.39 Atrial flutter HCC 96 I48.92 Chest x-ray/lung imaging R91.8 Anticoagulation Medication Management Chest sounds R09.89 Therapeutic drug monitoring Z51.81 Abnormal lipid finding E75.6 Long term (current) use of anticoagulants Z79.01 Echocardiogram R93.1 Coronary Atherosclerosis (CAD) EKG (long QT syndrome I45.81) R94.31 of native coronary artery, without angina pectoris I25.10 Abnormal Labs: Serum enzymes R74.8 with unstable angina pectoris HCC 87 I25.110 Coagulation profile R79.1 with other forms of angina pectoris HCC 88 I25.118 Abnormal blood gas R79.81 with unspecified angina pectoris HCC 88 I25.119 Angina of coronary artery bypass graft (NOS) w/o angina I25.810 Unspecified angina or ischemic chest pain HCC 88 I20.9 autologous artery coronary artery bypass graft(s) Prinzmetal angina (w/documented spasm) HCC 88 I20.1 with unstable angina pectoris HCC 87 I25.720 Stable angina HCC 88 I20.8 with other forms of angina pectoris HCC 88 I25.728 Unstable angina/Intermediate coronary syndrome HCC 87 I20.0 Chronic total occlusion of coronary artery I25.82 Cardiac/Circulatory Signs and Symptoms Other documented forms of chronic ischemic HD I25.89 Bradycardia R00.1 Lipoid Disorders Chest discomfort/chest pain (See book) R07.89 Dyslipidemia / Hyperlipidemia NOS E78.5 Intercostal pain R07.82 Pure Hypercholesterolemia E78.00 painful respiration R07.1 Familial hypercholesterolemia E78.01 Cough R05 Pure hyperglyceridemia E78.1 Debility, age related physical (debility) R54 Mixed hyperlipidemia (combo of E78.0- & E78.1) E78.2 Dizziness R42 Myocardial Infarction - The most basic codes Dyspnea, unspecified R06.00 MI, acute, STEMI (acute ≤ 28 days from episode) HCC 86 I21.3 Periodic breathing R06.3 MI, acute, NSTEMI HCC 86 I21.4 Snoring R06.83 MI, acute, STEMI (subsequent ≤ 28 days from initial MI) HCC 86 I22.9 Other forms of dyspnea R06.09 MI old, by EKG/Hx, no problem now I25.2 Edema, unspecified R60.9 Cardiomyopathy Generalized edema R60.1 Cardiomyopathy, ischemic I25.5 Localized edema R60.0 Cardiomyopathy, Dilated HCC 85 I42.0 Falls, repeated R29.6 Cardiomyopathy, unspecified (See other I42 choices) HCC 85 I42.9 Fluid overload E87.70 Cardiac/Circ. Status Codes, Hx & Screening Heart murmur, unspecified R01.1 Cardiac defibrillator in situ Z95.810 Benign and innocent cardiac murmurs R01.0 Cardiac pacemaker in situ Z95.0 Weakness R53.1 Heart valve replacement (mechanical) Z95.2 Other fatigue R53.83 Heart valve replacement (tissue) Z95.3 Other malaise R53.81 Personal History of Nausea R11.0 CABG Z95.1 Nausea w/vomiting R11.2 PCI (angioplasty w/ implant) Z95.5 Vomiting alone R11.11 Coronary angioplasty (only) status Z98.61 Palpitations R00.2 CVA/TIA Z86.73 Shortness of breath R06.02 DVT Z86.718 Sleep apnea G47.30 Corrected congenital mal. heart/circ system Z87.74 Syncope R55 Pulmonary embolism Z86.711 Tachycardia R00.0 Smoking Z87.891 Nicotine Dependence and Exposure Code Sudden cardiac arrest Z86.74 Cigarette, uncomplicated (no related illness) F17.210 Surgery to heart and great vessels Z98.890 in remission F17.211 Family History of in withdrawal F17.213 Family history of ischemic heart disease Z82.49 Vapor or "Other" uncomplicated F17.290 Sudden cardiac death Z82.41 in remission F17.291 Other cardiovascular conditions Z82.49 in withdrawal F17.293 Screening for Chewing tobacco, uncomplicated F17.220 Lipids Z13.220 in remission F17.221 Anemia Z13.0 in withdrawal F17.223 Cardiovascular disorder 2nd hand tobacco smoke exposure Z77.22 Hypertension Z13.6 Occupational tobacco smoke exposure Z57.31 Ischemic heart condition History of tobacco dependence Z87.891 Malformation, congenital Z13.89 Tobacco use, [no dependence] avoid Z72.0

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 11, 2018 3 HYPERTENSION, HEART DISEASE, AND RENAL DISEASE DX CODE SHEET

I10 Hypertension without HD or CKD Code Elevated blood pressure (not hypertension) Code I10 Hypertension (HTN), essential hypertension I10 Elevated blood pressure R03.0 I11 Hypertensive Heart Disease (HHD) When HTN & HD exist together, use HHD codes below & I50 code if heart failure exists Hypertensive Heart Disease incudes: Heart Failure (I50.-), Myocarditis (I51.4), Myocardial degeneration (I51.5), Cardiomegaly (I51.7), Other ill-defined heart disease (I51.89), or Unspecified heart disease (I51.9). HHD with heart failure (HF) Code also HF from [I50] HCC 85 I11.0 HHD without heart failure (HF) I11.9 Heart Failure (I50) Specificity Options Left heart failure, CHF and Other heart failure Right heart failure Left heart failure HCC 85 I50.1 Right heart failure, unspecified HCC 85 I50.810 End stage heart failure (Code also heart failure, I50.2-I50.43) HCC 85 I50.84 Acute right heart failure HCC 85 I50.811 Other heart failure HCC 85 I50.89 Chronic right heart failure HCC 85 I50.812 Biventricular heart failure HCC 85 I50.82 Acute on chronic right heart failure HCC 85 I50.813 High output heart failure HCC 85 I50.83 Right heart failure due to left heart failure HCC 85 I50.814 Congestive heart failure (CHF, unspecified) Avoid HCC 85 I50.9 Diastolic heart failure Systolic heart failure Chronic diastolic heart failure HCC 85 I50.32 Chronic systolic heart failure HCC 85 I50.22 Acute diastolic heart failure HCC 85 I50.31 Acute systolic heart failure HCC 85 I50.21 Acute on chronic diastolic heart failure HCC 85 I50.33 Acute on chronic systolic heart failure HCC 85 I50.23 Combined systolic and diastolic heart failure Chronic systolic and diastolic heart failure HCC 85 I50.42 Acute systolic and diastolic heart failure HCC 85 I50.41 Acute on chronic systolic and diastolic heart failure HCC 85 I50.43 I12 Hypertensive Chronic Kidney Disease (HCKD) When HTN & CKD exist together, use HCKD codes below & N18 code HCKD w/stage 1-4 CKD or stage unspecified I12.9 HCKD with stage 5 CKD or end stage (ESRD) HCC 136 I12.0 N18 Chronic Kidney Disease-Report stage w/HCKD above. Note: GFRs per National Kidney Foundation, 2017. CKD stage 1 GFR 90 or higher (Glomerular Filtration Rate) N18.1 CKD stage 5 GFR <15 HCC 136 N18.5 CKD stage 2 GFR 60-89 N18.2 End stage renal disease (ESRD) HCC 136 N18.6 CKD stage 3 GFR 30-59 N18.3 CKD w/o stage documented in medical record N18.9 CKD stage 4 GFR 15-29 HCC 137 N18.4 Dependence on renal dialysis HCC 134 Z99.2 I13 Hypertensive Heart Disease (HHD) and Chronic Kidney Disease (HCKD) (1) When HTN, HD & CKD exist together, use appropriate code I13 below (2) Report also the stage of CKD from above. (3) If heart failure exists, report the type of failure from I50 above. HHD w/CKD, stage 1-4 or undoc., code I13, If HF add I50 code. HHD with CKD, stage 5 or ESRD, code I13, if HF add I50 code. with heart failure (code also the failure from I50) HCC 85 I13.0 with heart failure (code also the failure from I50) HCC 85 & 136 I13.2 without heart failure I13.10 without heart failure HCC 136 I13.11 I16 Hypertensive Crisis. Code also any identified hypertensive disease (I10-I15)

According to the American Heart Association: Hypertensive urgency (I16.0) occurs when systolic blood pressure exceeds 180, or diastolic exceeding 110, without progressive organ dysfunction. Hypertensive emergency (I16.1) occurs when levels exceed 180 systolic or 120 diastolic, with impending or progressive organ damage. Also document any consequences of the uncontrolled pressure. Hypertensive urgency I16.0 Hypertensive emergency I16.1 Underdosing of Antihypertensive Drugs (common drugs listed below, check a current code book for other choices) In ICD10CM, Underdosing refers to taking less of a medication than is prescribed by a provider or manufacturer's instruction. Discontinuing the use of a RX on the patient's own initiative...is also classified as underdosing. ACE Inhibitors (e.g. Lisinopril, Lotensin, Zesteril) T46.4x6X Beta Blockers (e.g. Lopressor, Atenolol, Metoprolol) T44.7x6X Diuretics/thiazides (e.g. HCTZ) T50.2x6X Calcium Channel Blocker (e.g. Cardizem, Procardia) T46.1x6X 7th character code, replace "X" with A = initial (active) visit, D = follow-up, S = Sequela (X = A, D or S) Also code reason for underdosing: Intentional underdosing due to financial hardship Z91.120 Intentional underdosing for other reason Z91.128 Unintentional underdosing due to age-related debility Z91.130 Unintentional underdosing for other reason Z91.138 Always Code nicotine/tobacco status (F17 OR ZXX) with Hypertension Tobacco, nicotine dependence (cigarette) F17.210 Exposure, tobacco smoke; second-hand, environmental Z77.22 in remission F17.211 occupational exposure Z57.31 with withdrawal F17.213 History of nicotine dependence/tobacco use Z87.891 with other nicotine-induced disorder F17.218

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 11, 2018 4 RESPIRATORY DX CODE SHEET Bronchitis J20 & J44 Asthma J45 Code Bronchitis, acute; organism unknown J20.9 Asthma, if chronic obstructive, see COPD w/asthma left column Organism known, but no code exists it. J20.8 Asthma, mild & intermittent Bronchitis, acute; choose based on organism uncomplicated J45.20 mycoplasma pneumonia J20.0 with acute exacerbation J45.21 hemophilus influenzae J20.1 with status asthmaticus J45.22 streptococcus J20.2 Asthma, mild & persistent coxsackievirus J20.3 uncomplicated J45.30 parainfluenza virus J20.4 with acute exacerbation J45.31 respiratory syncytial virus (RSV) J20.5 with status asthmaticus J45.32 rhinovirus J20.6 Asthma, moderate & persistent echovirus J20.7 uncomplicated J45.40 Bronchitis, acute w/COPD codes to COPD HCC J44.0 with acute exacerbation J45.41 Bronchitis, chronic; choose from below with status asthmaticus J45.42 simple and chronic HCC J41.0 Asthma, severe & persistent obstructive without exacerbation HCC J44.9 uncomplicated J45.50 obstructive with (acute) exacerbation HCC J44.1 with acute exacerbation J45.51 mucopurulent HCC J41.1 with status asthmaticus J45.52 mixed simple & mucopurulent HCC J41.8 Asthma, severity not stated J45.909 with lower resp infection (code also infection) HCC J44.0 with acute exacerbation J45.901 with acute exacerbation of asthma HCC J44.1 with status asthmaticus J45.902 COPD J44 Asthma, exercise induced J45.990 Chronic Obstructive Pulmonary Disease HCC J44.9 Asthma, cough variant J45.991 with acute exacerbation HCC J44.1 Family hx asthma/lower resp disease Z82.5 with acute lower resp infection (code also infection) HCC J44.0 EMR ICD-10 Search Tips : Search Asthma by severity (e.g., mild, moderate or with asthma (code also Asthma type J45-) HCC J44.9 severe); then by quality (e.g., intermittent or persistent); then today's status with asthma exacerbation (code also asthma) HCC J44.1 (uncomplicated, exacerbation or asthmaticus). Always Code Tobacco Status F17 and ZXX Tobacco, nicotine dependence (cigarette) F17.210 Exposure, tobacco smoke; second-hand, environmental Z77.22 in remission F17.211 occupational exposure Z57.31 with withdrawal F17.213 History of nicotine dependence/tobacco use Z87.891 with other nicotine-induced disorder F17.218 Pneumonia J12, J14, J15 & J18 Respiratory S/S, Status & Hx Codes Pneumonia, no organism specified J18.9 Abnormal; chest sounds/rales R09.89 Pneumonia, viral, choose from below - x-ray of lung R91.8 adenovirus J12.0 pulmonary function studies R94.2 respiratory syncytial virus (RSV) J12.1 Bronchospasm, acute J98.01 parainfluenza virus J12.2 Chest pain on breathing R07.1 SARS-associated coronavirus J12.81 Cough (chronic) (if smoker's cough, use J41.0) R05 viral, unspecified J12.9 Cyanosis R23.0 Pneumonia, bacterial, organism unspecified J15.9 Dyspnea / respiratory distress R06.00 Pneumonia, bacterial, choose from below - Fatigue, lethargy, or decreased energy R53.83 hemophilus influenzae HCC J14 Fever R50.9 pseudomonas HCC J15.1 Hyperventilation R06.4 staphylococcus HCC J15.20 Hypoxia or Hypoxemia R09.02 streptococcus, Group A HCC J15.4 Oxygen dependence (supplemental) Z99.81 streptococcus, other than Group A HCC J15.4 Pleural effusion J90 anaerobes HCC J15.8 Respiratory; insufficiency R06.89 E.coli (Escherichia coli) HCC J15.5 Shortness of breath R06.02 other gram-negative bacteria HCC J15.6 Sputum, abnormal/excessive R09.3 bacteria, other than above HCC J15.8 Stridor R06.1 Pneumonia, MRSA HCC J15.212 Tightness, chest R07.89 Pneumonia, MSSA HCC J15.211 URI J06.9 Pneumonia, idiopathic, interstitial HCC J84.111 Wheezing R06.2 Emphysema J43 Status codes (assign when present) Emphysema, unilateral pulmonary HCC J43.0 Tracheostomy, status HCC Z93.0 panlobular emphysema HCC J43.1 Lung transplant status HCC Z94.2 centrilobular emphysema HCC J43.2 Personal history of; other emphysema, not listed here HCC J43.8 recurrent pneumonia Z87.01 unspecified, (when documentation does not identify) HCC J43.9 other respiratory diseases Z87.09

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 19, 2017

5 WEIGHT MANAGEMENT/NUTRITION DX CODE SHEET Weight Dx (Adult/Child) Pediatric BMI Code also, Adult or Peds BMI Code Code type from the left & BMI from the right. Code Abnormal weight gain R63.5 Overweight E66.3 85th to < 95th percentile for age Z68.53 Obesity complicating pregnancy O99.21- Obese E66.9 = / > 95th percentile for age Z68.54 Drug-induced obesity E66.1 Underweight R63.6 < 5th percentile for age Z68.51 Overweight E66.3 Underweight Conditions (code also BMI) Code also ADULT BMI from below or PED BMI from right Abnormal weight loss R63.4 BMI between 25.0 - 25.9 Z68.25 Failure to thrive, child R62.51 BMI between 26.0 - 26.9 Z68.26 Failure to thrive, adult R62.7 BMI between 27.0 - 27.9 Z68.27 Physical growth retardation R62.52 BMI between 28.0 - 28.9 Z68.28 due to malnutrition HCC E45 BMI between 29.0 - 29.9 Z68.29 Anorexia (appetite loss, excludes anorexia nervosa F50.0-) R63.0 Obesity due to excess calories E66.09 Screening Diagnoses Other Obesity E66.8 Screening for nutrition disorder Z13.21 Code also ADULT BMI from below or PED BMI from right Screening for other endocrine disorder (malnutrition) Z13.29 BMI between 30.0 - 30.9 Z68.30 Other Miscellaneous Dx BMI between 31.0 - 31.9 Z68.31 Inappropriate diet/eating habits Z72.4 BMI between 32.0 - 32.9 Z68.32 Inadequate diet causing nutritional deficiency E63.9 BMI between 33.0 - 33.9 Z68.33 Polyphagia (excessive eating) R63.2 BMI between 34.0 - 34.9 Z68.34 Here to discuss test findings Z71.2 BMI between 35.0 - 35.9 Z68.35 Dietary counseling and surveillance Z71.3 BMI between 36.0 - 36.9 Z68.36 Use additional code for associated condition BMI between 37.0 - 37.9 Z68.37 Lack of physical exercise Z72.3 BMI between 38.0 - 38.9 Z68.38 Worried well (concerns, but no problem) Z71.1 BMI between 39.0 - 39.9 Z68.39 "Resource-type" Additional Dx Morbid Obesity due to excess calories HCC E66.01 Lack of adequate food and safe drinking water Z59.4 Code also ADULT morbid obesity BMI from below Homelessness Z59.0 BMI between 40.0 - 44.9 HCC Z68.41 Inadequate housing Z59.1 BMI between 45.0 - 49.9 HCC Z68.42 Low income Z59.6 BMI between 50.0 - 59.9 HCC Z68.43 Extreme poverty Z59.5 BMI between 60.0 - 69.9 HCC Z68.44 Insufficient social insurance/welfare support Z59.7 BMI 70 or greater HCC Z68.45 Deficiencies, Vitamins Underweight R63.6 Vitamin A E50.- BMI of 19.9 or less, adult Z68.1 Thiamine E51.- Malnutrition E40-E46 Niacin E52 Unspecified protein-calorie malnutrition HCC E46 Folate (folic acid) E53.8 Malnutrition; Protein-calorie, mild HCC E44.1 Vitamin C E54 Malnutrition; Protein-calorie, moderate HCC E44.0 Vitamin D E55.9 Malnutrition; Protein-calorie, severe HCC E43 Vitamin E E56.0 Nutritional marasmus (severe) HCC E41 Vitamin K E56.1 Kwashiorkor (rare in US) HCC E40 Deficiencies, Elements Cachexia (wasting syndrome) HCC R64 Calcium E58 Starvation Zinc E60 Initial visit T73.0xxA Other E61.- FU visit T73.0xxD Other/Miscellaneous Diagnoses Visit for sequela (code also the condition ) T73.0xxS Pickwickian Syndrome (Morbid obese w/alveolar hypoventilation) HCC E66.2 Obstructive sleep apnea G47.33

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 19, 2017 6 PREGNANCY DX CODE SHEET Supervision Normal Pregnancy More Complications of Pregnancy Assign Supervision Normal Pregnancy if no complications or Bleeding, TA, Preterm & Post Dates Root Code * Trimester risk factors exist. Code Z34 codes may not be reported Spotting, Not hemorrhage O26.85* 123 with other pregnancy codes. Root Code * Trimester Hemorrhage (other) in early pregnancy O20.8 First normal pregnancy Z34.0* 1 2 3 Threatened abortion O20.0 Subsequent normal pregnancy Z34.8* 1 2 3 Preterm labor without delivery O60.0* 23 Routine postpartum follow-up visit Z39.2 False labor before 37 weeks O47.0* 23 Pregnancy state, incidental Z33.1 Post term pregnancy >40 wks to 42 wks O48.0 Assign gestational weeks for all visits beyond 42 weeks O48.1 <8 weeks Z3A.01 26 weeks Z3A.26 8 weeks Z3A.08 27 weeks Z3A.27 Other Complications 9 weeks Z3A.09 28 weeks Z3A.28Miscarriage/SAB w/o comp; Incomplete O03.4 10 weeks Z3A.10 29 weeks Z3A.29 Miscarriage/SAB w/o comp; Complete O03.9 11 weeks Z3A.11 30 weeks Z3A.30 Missed abortion O02.1 12 weeks Z3A.12 31 weeks Z3A.31 Placenta previa w/o hemorrhage O44.0* 123 13 weeks Z3A.13 32 weeks Z3A.32 Placenta previa with hemorrhage O44.1* 123 14 weeks Z3A.14 33 weeks Z3A.33 HTN, pre-existing O10.01* 123 15 weeks Z3A.15 34 weeks Z3A.34 HTN, gestational w/o significant proteinuria O13.* 123 16 weeks Z3A.16 35 weeks Z3A.35 Pre-eclampsia, mild to moderate O14.0* 23 17 weeks Z3A.17 36 weeks Z3A.36 Pre-eclampsia, severe O14.1* 23 18 weeks Z3A.18 37 weeks Z3A.37 HELLP syndrome O14.2* 23 19 weeks Z3A.19 38 weeks Z3A.38 Eclampsia O15.0* 23 20 weeks Z3A.20 39 weeks Z3A.39 Edema, Gestational O12.0* 123 21 weeks Z3A.21 40 weeks Z3A.40 Proteinuria, Gestational O12.1* 123 22 weeks Z3A.22 41 weeks Z3A.41 Edema & proteinuria, Gestational O12.2* 123 23 weeks Z3A.23 42 weeks Z3A.42 Abnormal GTT in pregnancy O99.810 24 weeks Z3A.24 > 42 weeks Z3A.49 GBS carrier in pregnancy O99.820 25 weeks Z3A.25 Unspecified Z3A.00 Uterine size date discrepancy O26.84* 123 Supervision of High Risk Pregnancy Pre-existing Diabetes Assign High Risk Pregnancy codes when: DM2, pre-existing O24.11* 123 (1) Patient had a problem in previous pregnancy or, DM2, pre-existing, postpartum/puerperium O24.13 (2) has had a condition that may complicate this pregnancy or, Add code for all DM2's on insulin HCC Z79.4 (3) has other factors that increase risk in current pregnancy. DM1, pre-existing O24.01* 123 * May code high risk w/O00‐O08, but not for same condition. DM1, pre-existing, postpartum/puerperium O24.03 * Do not code high risk O09.xx codes with Z34.xx codes. Gestational Diabetes Replace the * with trimester 1, 2 or 3 Root Code * Trimester diet controlled, antepartum O24.410 High risk due to; insufficient antenatal care O09.3* 1 2 3 insulin controlled, antepartum O24.414 history of pre-term labor O09.21* 1 2 3 oral hypoglycemic controlled, antepartum O24.415 history of infertility O09.0* 1 2 3 diet controlled, puerperium O24.430 history of ectopic pregnancy O09.1* 1 2 3 insulin controlled, puerperium O24.434 history of molar pregnancy O09.A* 1 2 3 hypoglycemic med controlled, puerperium O24.435 current social problems; O09.7* 123History of Gestational Diabetes Z86.32 elderly primigravida age =/> 35@ delivery O09.51* 123 Smoking Assign also F17.- code below to identify type of nicotine elderly multigravada age =/> 35 @ delivery O09.52* 1 2 3 Smoking tobacco, antepartum O99.33* 123 young primigravida age< 16 @ delivery O09.61* 1 2 3 Smoking tobacco, puerperium O99.335 young multigravida age< 16 @ delivery O09.62* 123 Nicotine Dependence, Exposure, History & Use poor OB Hx, or poor reproductive Hx O09.29* 1 2 3 Cigarette dependence, uncomp (no related illness) F17.210 other documented reason for high risk O09.89* 1 2 3 Cigarette dependence, in remission F17.211 Complications of Pregnancy Cigarette dependence with withdrawal F17.213 Anemia Assign also code for type of anemia O99.01* 1 2 3 Vapor/Other tobacco product, dependence F17.290 UTI in pregnancy O23.4* 1 2 3 Exposure-environmental tobacco smoke Z77.22 Bladder infection during pregnancy O23.1* 1 2 3 Personal history of nicotine dependence Z87.891 Kidney infection during pregnancy O23.0* 123Alcohol & Drug Use Assign also codes re: abuse/dependence Vomiting, mild, before end of 20 weeks O21.0 Alcohol use in pregnancy Assign also F10 - O99.31* 123 Vomiting after 20 weeks (excessive vomiting) O21.2 Drug use in pregnancy Assign F11-F19 code O99.32* 123 Obesity, Weight & Malnutrition Mental Disorders Obesity Also report specific type of obesity E66.- O99.21* 1 2 3 Assign this code plus a code for the O99.34* 123 Weight gain, excessive O26.0* 123specific condition. See F20-F99. Weight gain, low/inadequate O26.1* 1 2 3 Anxiety, generalized F41.1 Malnutrition in pregnancy O25.1* 1 2 3 Bipolar, unspec (more options avail.) HCC F31.9

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 19, 2017 7 FAMILY PLANNING AND STI DX CODE SHEET Family Planning/Contraception Code Female GYN Signs/Symptoms Code INITIAL CONTRACEPTION - by method Amenorrhea, unspecified N91.2 Advice only today regarding contraception Z30.09 Cervicitis, unspecified organism N72 Oral contraceptive pill Z30.011 DUB, unspecified N93.8 Injectable contraceptive Z30.013 Dysmenorrhea cramps/pain N94.6 IUD prescribed but no insertion today Z30.014 Dyspareunia, superficial painful intercourse N94.11 IUD insertion today Z30.430 Dyspareunia, deep N94.12 Vaginal ring hormone Z30.015 Dypareunia, other specified N94.19 Transdermal patch hormone Z30.016 Irregular menstrual cycle N92.6 Implantable subdermal Z30.017 Leukorrhea DC not confirmed infection N89.8 Other method (other than above; e.g. Condoms) Z30.018 Menorrhagia N92.0 EC Emergency contraception Z30.012 Metrorrhagia / break through bleed N92.1 Follow-Up Contraception - by method Oligomenorrhea infrequent/light N91.5 Advice only today regarding contraception Z30.09 Pain, abdominal generalized R10.84 Oral contraceptive pill Z30.41 Pain, pelvic R10.2 Injectable contraceptive Z30.42 Premenstrual tension syndrome N94.3 IUD: insertion today Z30.430 Vaginal discharge N89.8 Interim Follow-up/Routine checking Z30.431 Vaginitis, bacterial Organism known? See below or ICD10 N76.0 Removal of IUD only today Z30.432 Vaginitis, yeast Candidiasis B37.3 Removal and reinsertion of IUD Z30.433 Vaginitis, acute Organism known? see below or ICD10 N76.0 Vaginal ring hormone Z30.44 Lesions Transdermal patch hormone Z30.45 Herpetic ulceration vulva A60.04 Implantable subdermal Z30.46 Warts, anogenital (veneral) C. acuminatum A63.0 Other method (other than above; e.g. Condoms) Z30.49 Conditions Reserved for Males EC Emergency contraception Z30.012 Painful coitus or ejaculation, male N53.12 Preventive Examinations Benign cyst of testis N44.2 ANNUAL, COMPLETE: no abnormal findings Z00.00 Erectile dysfunction, organic N52.9 with abnormal findings today, (code also) Z00.01 Hematospermia R36.1 If cervical pap today, code also Z12.4 Herpesviral infection: penis A60.01 GYN EX ONLY: no abnormal findings Z01.419 Balanitis (Add Code - infectious agent: B95-B97) N48.1 with abnormal findings today, (code also) Z01.411 Orchitis N45.2 Screening (Patient w/o signs/symptoms) Epididymitis N45.1 Pregnancy test today - negative Z32.02 Epididymo-orchitis N45.3 Positive results today Z32.01 Penile discharge R36.9 Results cannot be confirmed today Z32.00 Prostatitis, acute N41.0 Anemia, iron deficiency Z13.0 Stress incontinence, male N39.3 Breast cancer screening exam only today Z12.39 Varicocele of scrotum I86.1 Breast - ordering mammogram today Z12.31 Uretheritis, nonspecific N34.1 Chlamydial infection screening Z11.8 Syphilis HIV (screening for) Z11.4 Primary, genital A51.0 HPV (screening for) Z11.51 Primary, anal A51.1 Screening Other STD/STI Z11.3 Primary, other sites A51.2 Urinary Concerns Infections- By Organism & Anatomy Cystitis, acute w/o hematuria N30.00 Candidiasis, vulvovaginitis or thrush Female B37.3 with hematuria N30.01 Cystitis and urethritis Female/Male B37.41 Dysuria R30.0 Chlamydial Infection, vulvovaginitis FE A56.02 Hematuria, gross R31.0 Cystitis and urethritis FE/M A56.01 Hematuria, microscopic - benign R31.1 Cervicitis FE A56.09 Asymptomatic microscopic hematuria R31.21 Anus and rectum FE/M A56.3 Other microscopic hematuria R31.29 Lower GU tract, anatomy unspecified FE/M A56.00 Stress incontinence, female N39.3 Other chlamydial infect. (eg, epididymitis/orchitis) FE/M A56.19 Urethritis, unspecified N34.1 Gonorrheal Infection, vulvovaginitis A54.02 Urinary frequency R35.0 Cystitis and urethritis Female/Male A54.01 Urinary hesitancy R39.11 Cervicitis FE A54.03 Urinary straining R39.16 Anus FE/M A54.6 Urinary urgency R39.15 Lower GU tract, anatomy unspecified FE/M A54.00 UTI (urinary tract infection) (ID organism) N39.0

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - April 5, 2018 8 FAMILY PLANNING AND STI DX CODE SHEET Infections- By Organism & Anatomy - Cont. Code Risk Issues (carrier/suspected carrier) Code Herpesviral, anogenital [h simplex] vaginitis FE A60.04 GC carrier or suspected carrier Z22.4 Cervicitis FE A60.03 STI/STD carrier/suspected carrier Z22.4 Perianal skin and rectum FE/M A60.1 Hepatitis B; carrier B18.1 Penis M A60.01 Hepatitis C; carrier B18.2 Male genital organs, other than penis M A60.02 High risk sexual behavior Herpes, urogenic, unspecified FE/M A60.00 Heterosexual Z72.51 Hepatitis A, acute B15.9 Bisexual Z72.53 Hepatitis B, acute B16.9 Homosexual Z72.52 Hepatitis C, chronic HCC B18.2 Social Issues as an Add'l Dx HIV positive & asymptomatic (not AIDS) HCC Z21 Homelessness Z59.0 HIV/AIDS HCC B20 Inadequate housing Z59.1 HPV, Human papillomavirus A63.0 Lack of adequate food and drinking water Z59.4 Trichomoniasis Infection, vulvovaginitis FE A59.01 Extreme poverty Z59.5 Cystitis and urethritis FE/M A59.03 Low income Z59.6 Cervicitis FE A59.09 Insufficient social ins and welfare support Z59.7 PID, acute pelvic inflammatory disease N73.0 Child in welfare custody (foster care) Z62.21 PID, chronic N73.1 Institutional upbringing Z62.22 Nicotine Dependence vs. Tobacco Use & Exposure Other upbringing away from parents Z62.29 Cigarette, uncomplicated (no related illness) F17.210 Problems in relationship w/spouse/partner Z63.0 in remission F17.211 Physical Abuse Dx Codes in withdrawal F17.213 Replace dash (-) with; A = initial (active tx); Vapor or "Other" uncomplicated F17.290 D = FU (healing); or S = sequela in remission F17.291 Suspected abuse; physical abuse of an adult T76.11x- in withdrawal F17.293 sexual abuse of adult T76.21x- Chewing tobacco, uncomplicated F17.220 physical abuse of a child T76.12x- in remission F17.221 sexual abuse of a child T76.22x- in withdrawal F17.223 Confirmed abuse; physical abuse of adult T74.11x- 2nd hand tobacco smoke exposure Z77.22 sexual abuse of adult T74.21x- Occupational tobacco smoke exposure Z57.31 physical abuse of a child T74.12x- History of tobacco dependence Z87.891 sexual abuse of a child T74.22x- Tobacco use, [no dependence] avoid Z72.0 Abuse (physical) of adult has now been ruled-out Z04.71 Counseling Abuse (physical) of child has now been ruled-out Z04.72 Counseling re: STI/STD Z71.89 Underdosing of Prescribed Medication by Patient Counseling re: HIV negative or positive Z71.7 Code first, underdosing of medication (T36-T50) with fifth or sixth Exposure as a Dx character of "6", then code intent and reason (below) Infection, primarily sexual transmission Z20.2 Replace dash (-) with; A = initial (active tx); HIV, exposure to Z20.6 D = FU (healing); or S = sequela History Of 1. Underdosing, oral contraceptives See ICD for other meds T38.4x6- Personal hx of infection (e.g., STD) Z86.19 2. Then code also intent and reason from below. Procreation Dx INTENTIONAL underdosing of med(s) by patient; Procreative counseling Z31.69 due to financial hardship Z91.120 using natural family planning Z31.61 for any other reason Z91.128 Infertility, female NOS N97.9 UNINTENTIONAL underdosing of med(s) by pt; Infertility, male NOS N46.9 due to age-related debility Z91.130 for any other reason Z91.138

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - April 5, 2018 9 PEDIATRIC DX CODE SHEET Preventive Visits Code ADHD Routine infant or child check Z00.129 predominately inattentive type F90.0 with abnormal findings (code findings) Z00.121 predominately hyperactive type F90.1 Newborn < 8 days old (e.g., weight/color check) Z00.110 combined F90.2 8-28 days old Z00.111 Asthma Code Exam of the ears and hearing (normal exam) Z01.10 Asthma, mild & intermittent following failed hearing screening Z01.110 uncomplicated J45.20 with other abnormal findings (code findings) Z01.118 with acute exacerbation J45.21 Exam of the eyes/vision (normal exam) Z01.00 with status asthmaticus J45.22 with abnormal findings (code findings) Z01.01 Asthma, mild & persistent Sports physical Z02.5 uncomplicated J45.30 Adoption exam Z02.82 w/acute exacerbation J45.31 Drivers license (e.g., DOT) Z02.4 with status asthmaticus J45.32 Annual pap and/or pelvic (normal exam) Z01.419 Asthma, moderate & persistent with abnormal findings (code findings) Z01.411 uncomplicated J45.40 Screenings with acute exacerbation J45.41 ● Screening; unspecified developmental delays Z13.40 with status asthmaticus J45.42 ● autism Z13.41 Asthma, severe & persistent ● for global developmental delays (milestones) Z13.42 uncomplicated J45.50 ● for other developmental delays Z13.49 with acute exacerbation J45.51 Immunizations with status asthmaticus J45.52 Encounter for immunizations Z23 Asthma, severity not stated J45.909 Immunization not carried; caregiver refusal Z28.82 with acute exacerbation J45.901 Encounter for prophylactic immunotherapy for RSV Z29.11 with status asthmaticus J45.902 Otitis and Other Ear Infections Asthma, exercise induced J45.990 OM, nonsuppurative, serous & acute; RIGHT H65.01 Asthma, cough variant J45.991 left ear H65.02 Family history of asthma Z82.5 bilateral H65.03 Conjunctivitis recurrent right ear H65.04 Conjunctivitis, mucopurulent H10.9 recurrent left ear H65.05 Acute Follicular recurrent bilateral H65.06 right eye H10.011 OM, nonsuppurative, serous & CHRONIC; RIGHT H65.21 left eye H10.012 left ear H65.22 bilateral H10.013 bilateral H65.23 Other mucopurulent OM, suppurative & acute & TM intact RIGHT H66.001 right eye H10.021 left ear H66.002 left eye H10.022 bilateral H66.003 bilateral H10.023 recurrent right ear H66.004 Acute atopic recurrent left ear H66.005 right eye H10.11 recurrent bilateral H66.006 left eye H10.12 OM, suppurative & acute TM rupture, RIGHT H66.011 bilateral H10.13 left ear H66.012 Serous, except viral bilateral H66.013 right eye H10.231 recurrent right ear H66.014 left eye H10.232 recurrent left ear H66.015 bilateral H10.233 recurrent bilateral H66.016 viral B30.9 OM, suppurative, tubotympanic, chronic, RIGHT H66.11 Other Respiratory and ENT Dx left ear H66.12 Bronchitis J20.9 bilateral H66.13 Ceruman impaction, Right ear H61.21 Otitis externa, acute Right ear H60.501 left ear H61.22 left ear H60.502 bilateral H61.23 bilateral H60.503 Cough R05 Otitis externa, chronic Right ear H60.61 Epistaxis R04.0 left ear H60.62 Gastroenteritis K52.9 bilateral H60.63 Otalgia, Right ear H92.01 Depression - Major Depressive Disorder See DSM5 pg. 160 left ear H92.02 MDD, single episode, mild HCC 58 F32.0 Pneumonia J18.9 MDD, single episode, moderate HCC 58 F32.1 Swimmer's ear, Right ear H60.331 MDD, single episode, severe w/o psychotic feat. HCC 58 F32.2 left ear H60.332 MDD, single episode, severe w/psychotic feat. HCC 58 F32.3 bilateral H60.333 MDD, single episode, in partial remission HCC 58 F32.4 Tonsillitis, acute J03.90 MDD, single episode, in full remission HCC 58 F32.5 chronic J35.01 Adjustment disorder with depressed mood F43.21 Adenoiditis, chronic J35.02 Tonsillitis with adenoiditis, chronic J35.03 URI J06.9 Viral syndrome B97.89

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 25, 2018 10 PEDIATRIC DX CODE SHEET Rhinitis - Code tobacco exposure Code FOREIGN BODY (7th - A=initial, D= FU, S=sequela) Code acute J00 Nostril T17.1XX- allergic J30.9 Ear; RIGHT T16.1XX- chronic J31.0 LEFT T16.2XX- Laryngitis, acute w/o obstruction J04.0 Dermatology with obstruction (croup) J05.0 Acne L70.8 chronic J37.0 Eczema L30.9 Pharyngitis, acute J02.9 Impetigo L01.00 Sinusitis - Code tobacco exposure LICE; Head B85.0 ethmoidal J01.20 Body B85.1 recurrent J01.21 Rash R21 chronic J32.2 Plantar wart B07.0 frontal, acute J01.10 Sunburn; First degree L55.0 recurrent J01.11 Second degree L55.1 chronic J32.1 Urticaria L50.9 maxillary, acute J01.00 GI/GU Dx recurrent J01.01 Abdominal Pain, acute R10.0 chronic J32.0 RUQ R10.11 pansinusitis, acute J01.40 LUQ R10.12 recurrent J01.41 RLQ R10.31 chronic J32.4 LLQ R10.32 sphenoid, acute J01.30 Epigastric R10.13 recurrent J01.31 Periumbilical R10.33 chronic J32.3 Generalized R10.84 Weight Management Dental caries, unspecified K02.9 Code type from left & BMI from right. BMI codes are for ages 2-20. Diarrhea R19.7 Overweight E66.3 85th to < 95th percentile for age Z68.53 UTI N39.0 Obese E66.9 = / > 95th percentile for age Z68.54 Constipation K59.00 Underweight R63.6 < 5th percentile for age Z68.51 GERD K21.9 Failure to Thrive child R62.51 Diabetes Type 1 HCC 19 E10.9 Newborn P92.6 Diabetes Type 2 HCC 19 E11.9 Delayed milestones (childhood) R62.0 Dysuria R30.0 Short stature R62.52 Nausea R11.0 Sprain 7th character - A=initial, D=subsequent, S=sequela with vomiting R11.2 RIGHT ankle, unspecified ligament S93.401- Vomiting alone R11.11 LEFT ankle, unspecified ligament S93.402- Signs/Symptoms RIGHT ankle, deltoid ligament S93.421- Chest pain R07.9 LEFT ankle, deltoid ligament S93.422- Dizziness R42 Fatigue R53.83 Tobacco and Nicotine Concerns Fever R50.9 Exposure to environmental tobacco smoke Z77.22 Headache R51 Cigarette, uncomplicated (nor directly related to illness) F17.210 TB Study: Contact or exposure to TB Z20.1 in remission F17.211 Nonspec. Reac. to TB skin test w/o active TB R76.11 in withdrawal F17. 213 Screening respiratory tuberculosis Z11.1 Other tobacco product, uncomplicated F17.290 Syncope R55 in remission F17.291 Counseling For: in withdrawal F17.293 Alcohol abuse Z71.41 Tobacco use, [no dependence] avoid Z72.0 Contraception Z30.09 Occupational exposure to tobacco smoke Z57.31 Dietary (Add code: BMI & underlying condition) Z71.3 History of nicotine dependence Z87.891 Tobacco Z71.6 Underdosing by Patient Coder - Code drug from T36-T50 See ICD-10-CM for other counseling diagnoses intentional NEC Z91.128 Peds - Misc due to financial hardship Z91.120 Zika virus A92.5 unintentional NEC Z91.138 Family history of SIDS Z84.82 Maternal Use Drugs Affecting Newborn ● Newborn affected by maternal use; opiates P04.14 ● antidepressants P04.15 ● amphetamines P04.16 ● sedative-hypnotics P04.17

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 25, 2018 11 PREVENTION DX CODE SHEET Typical Preventive Exams Code Screening for Certain Developmental Disorders in Childhood General adult med exam (Annual Exam) ● Screening; unspecified developmental delays Z13.40 Z00.00 without abnormal findings ● autism Z13.41 with abnormal findings Z00.01 ● for global developmental delays (milestones) Z13.42 code also the abnormal finding code also ● for other developmental delays Z13.49 Completed Pap with above, code also Z12.4 Screening for Mental Health and Behavioral Disorders Routine "GYN only" exam (with/wo Pap) ● Screening; mental health & behavioral disorders, unspecZ13.30 Z01.419 without abnormal findings ● depression Z13.31 with abnormal findings Z01.411 ● maternal depression Z13.32 code also the abnormal finding code also ● other mental health and behavioral disorders Z13.39 WCC without abnormal findings Z00.129 Other Screening Studies WCC with abnormal findings Z00.121 Pregnancy test today - negative Z32.02 code also the abnormal finding code also Positive results today Z32.01 Newborn Ck, 1-7 days old (e.g., wt/color) Z00.110 Results cannot be confirmed today Z32.00 if abnormalities, assign additional code(s) code also Anemia (iron deficient) Z13.0 Newborn Ck, 8-28 days old (e.g., wt/color) Z00.111 Cardiovascular disorders Z13.6 if abnormalities, assign additional code(s) code also Developmental disorders in childhood Z13.4 Special Reasons Dx Codes Diabetes Z13.1 Sports Z02.5 Poisoning (chemical / heavy metal-lead) Z13.88 Immigration, naturalization Z02.89 HIV Z11.4 School admission Z02.0 Lipoid disorders Z13.220 Pre-employment Z02.1 Osteoporosis Z13.820 Recruitment to armed forces Z02.3 Routine cervical Pap smear Z12.4 Issue of other med certificate Z02.79 Respiratory TB Z11.1 Paternity Z02.81 Sexually Transmitted Infection Z11.3 Adoption Z02.82 Thyroid disorders Z13.29 Blood-alcohol & blood-drug Z02.83 Initial Contraception - by method Medicare Preventive Visit and Service Diagnoses Advice only today regarding contraception Z30.09 Welcome to MCare Visit (Pts 1st year in Medicare) Oral contraceptive pill Z30.011 Z00.00 Medicare Annual Wellness Visit Injectable contraceptive Z30.013 Obesity counseling (Code also obesity type & BMI) Z71.3 IUD prescribed but no insertion today Z30.014 Screening; mammogram for breast CA Z12.31 IUD insertion today Z30.430 cardiovascular disorder Z13.6 Vaginal ring hormone Z30.015 diabetes Z13.1 Transdermal patch hormone Z30.016 eye and/or ear disorder Z13.5 Implantable subdermal Z30.017 HIV Z11.4 Other method (other than above; e.g. Condoms) Z30.018 HPV Z11.51 EC Emergency contraception Z30.012 sexually transmitted infection Z11.3 Follow-Up Contraception - by method prostate malignancy (could be exam or PSA) Z12.5 Advice only today regarding contraception Z30.09 Special screening malignant neoplasm; other sites Z12.89 Oral contraceptive pill Z30.41 Screening for other disorders (without a specific Dx code) Z13.89 Injectable contraceptive Z30.42 Screening Dx's IUD: insertion today Z30.430 Paps Interim Follow-up/Routine checking Z30.431 Routine cervical pap smear Z12.4 Removal of IUD only today Z30.432 Mcare screening pap; cervical; low risk, q2 yrs Z12.4 Removal and reinsertion of IUD Z30.433 high risk, q1yr (code also - other spec risk factors Z91.89) Z12.4 Vaginal ring hormone Z30.44 vaginal (if applicable code also - absence of uterus) Z12.72 Transdermal patch hormone Z30.45 Pap to confirm normal after abnormal Z01.42 Implantable subdermal Z30.46 Female Screening - Miscellaneous Other method (other than above; e.g. Condoms) Z30.49 Breast - ordering mammogram today Z12.31 Immunization Dxs Chlamydial infection screening Z11.8 One Dx code for any number of Immunizations. Z23 HPV Human papilloma virus Z11.51 Underimmunized (as a diagnosis) Z28.3 High risk sexual behavior (heterosexual) Z72.51 Vaccine not given today because: Acute illness Z28.01 Chronic illness/condition Z28.02 Immune compromised state Z28.03 Allergy to vaccine or component Z28.04 Other contraindication Z28.09 Patient's belief or group pressure Z28.1 Patient's refusal Z28.21 Caregiver refusal Z28.82 Patient had the disease Z28.81

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 12 PREVENTION DX CODE SHEET Special Exams: Eyes/Vision and Ears/Hearing Nicotine Dependence vs Tobacco Use and Exposure Eyes/vision, without abnormal findings Z01.00 Cigarette, uncomplicated (no related illness) F17.210 with abnormal findings (code findings) Z01.01 in remission F17.211 Screening for glaucoma Z13.5 in withdrawal F17.213 Ears/hearing, without abnormal findings Z01.10 Vapor or "Other" uncomplicated F17.290 with other abnormal finding (code findings) Z01.118 in remission F17.291 following failed hearing screen Z01.110 in withdrawal F17.293 Counseling For (as a diagnosis) Chewing tobacco, uncomplicated F17.220 Diet (Add code: BMI, underlying condition) Z71.3 in remission F17.221 Exercise Z71.82 in withdrawal F17.223 Injury prevention Z71.89 2nd hand tobacco smoke exposure Z77.22 Drug abuse counseling (Type: F11-F16, F18-F19) Z71.51 Occupational tobacco smoke exposure Z57.31 Alcohol abuse counseling Z71.41 History of nicotine dependence Z87.891 Social Determinates Tobacco use, [no dependence] avoid Z72.0 Illiteracy and low-level literacy Z55.0 Personal History of Cancer Underachievement in school Z55.3 Breast Z85.3 Edu. maladjustment, discord w/teachers & classmates Z55.4 Edu. maladjustment, Cervix uteri discord w/teachers & classmates Z85.41 Unemployment, unspecified Z56.0 Other parts of uterus Z85.42 Change of job Z56.1 Colon Z85.038 Threat of job loss Z56.2 Prostate Z85.46 Discord with boss and workmates Z56.4 Bladder Z85.51 Other physical and mental strain related to work Z56.6 Family History of Homelessness Z59.0 Breast cancer Z80.3 Inadequate housing Z59.1 Colon cancer Z80.0 Person living in residential institution Z59.3 Colonic polyps Z83.71 Lack of adequate food and safe drinking water Z56.4 Diabetes Z83.3 Extreme poverty Z59.5 Cardiovascular disease Z82.49 Insufficient social insurance and welfare support Z59.7 Other housing/economic circumstance Z59.8 Problems related to living alone Z60.2 Acculturation difficulty Z60.3 Social exclusion and rejection Z60.4 Other problems related to social environment Z60.8 Foster care (status) Z62.21 Family disrupt; due to military deployment Z63.31 due to other absence of family member Z63.32 due to divorce/legal separation Z63.5 due to return from military deployment Z63.71 Problem related to primary support group, unspecified Z63.9 Conviction civil/criminal proceedings w/o imprisonment Z65.0 Imprisonment and other incarceration Z65.1 Lack of physical exercise Z72.3 Inappropriate diet and eating habits Z72.4 Burn-out Z73.0 Type A behavoir pattern Z73.1 Stress, not elsewhere classified Z73.3 Inadequate social skills, not elsewhere classified Z73.4 Social role conflict, not elsewhere classified Z73.5 Limitation of activites due to disability Z73.6 No household member to render care Z74.2 Holiday relief care Z75.5 Personal history of adult physical and sexual abuse Z91.410

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 13 ACUTE ILLNESS DX CODE SHEET Otitis and Other Ear Concerns Code Conjunctivitis - Continued Code OM, nonsuppurative, serous & acute; RIGHT H65.01 Other mucopurulent left ear H65.02 right eye H10.021 bilateral H65.03 left eye H10.022 recurrent right ear H65.04 bilateral H10.023 recurrent left ear H65.05 Acute atopic recurrent bilateral H65.06 right eye H10.11 OM, nonsuppurative, serous & CHRONIC; RIGHT H65.21 left eye H10.12 left ear H65.22 bilateral H10.13 bilateral H65.23 Serous, except viral OM, suppurative & acute & TM intact RIGHT H66.001 right eye H10.231 left ear H66.002 left eye H10.232 bilateral H66.003 bilateral H10.233 recurrent right ear H66.004 Viral B30.9 recurrent left ear H66.005 Other Respiratory and ENT Dx recurrent bilateral H66.006 Bronchitis J20.9 OM, suppurative & acute TM rupture, RIGHT H66.011 Ceruman impaction, Right ear H61.21 left ear H66.012 left ear H61.22 bilateral H66.013 bilateral H61.23 recurrent right ear H66.014 Cough R05 recurrent left ear H66.015 Epistaxis R04.0 recurrent bilateral H66.016 Otalgia, Right ear H92.01 OM, suppurative, tubotympanic, chronic, RIGHT H66.11 left ear H92.02 left ear H66.12 Pneumonia J18.9 bilateral H66.13 Swimmer's ear, Right ear H60.331 Otitis externa, acute Right ear H60.501 left ear H60.332 left ear H60.502 bilateral H60.333 bilateral H60.503 Tonsillitis, acute J03.90 Otitis externa, chronic Right ear H60.61 chronic J35.01 left ear H60.62 Adenoiditis, chronic J35.02 bilateral H60.63 Tonsillitis with adenoiditis, chronic J35.03 Rhinitis - Code tobacco exposure URI J06.9 acute J00 Viral syndrome B97.89 allergic J30.9 GI/GU Dxs chronic J31.0 Abdominal Pain, acute R10.0 Laryngitis, acute w/o obstruction J04.0 RUQ R10.11 with obstruction (croup) J05.0 LUQ R10.12 chronic J37.0 RLQ R10.31 Pharyngitis, acute J02.9 LLQ R10.32 streptococcal J02.0 Epigastric R10.13 Sinusitis - Code tobacco exposure Periumbilical R10.33 ethmoidal J01.20 Generalized R10.84 recurrent J01.21 Gastroenteritis K52.9 chronic J32.2 Allergic (Add code: food allergy = Z91.01-, Z91.02-) K52.2- frontal, acute J01.10 Diarrhea R19.7 recurrent J01.11 UTI N39.0 chronic J32.1 Acute cystitis without hematuria N30.00 maxillary, acute J01.00 Acute cystitis with hematuria N30.01 recurrent J01.01 Acute pyelonephritis N10 chronic J32.0 Diverticulitis of small intestine without; pansinusitis, acute J01.40 perforation or abscess w/o bleeding K57.12 recurrent J01.41 perforation with bleeding K57.13 chronic J32.4 Diverticulitis of large intestine without; sphenoid, acute J01.30 perforation or abscess w/o bleeding K57.32 recurrent J01.31 of perforation with bleeding K57.33 chronic J32.3 Constipation K59.00 Conjunctivitis GERD K21.9 Conjunctivitis, mucopurulent H10.9 Diabetes Type 1 HCC E10.9 Acute Follicular Diabetes Type 2 HCC E11.9 right eye H10.011 Vomiting alone R11.11 left eye H10.012 Nausea R11.0 bilateral H10.013 with vomiting R11.2

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 20, 2017 14 ACUTE ILLNESS DX CODE SHEET GI/GU Dxs - Continued Other Signs/Symptoms Dysuria R30.0 Chest pain R07.9 Dental caries, unspecified K02.9 Dizziness R42 Allergy to milk products Z91.011 Fatigue R53.83 E. Coli as cause of disease classified elsewhere B96.20 Fever R50.9 Tobacco and Nicotine Concerns Headache R51 Exposure to environmental tobacco smoke Z77.22 TB Study: Contact or exposure to TB Z20.1 Cigarette, uncomplicated (no directly related illness) F17.210 Nonspecific reaction TB test w/o active TB R76.11 Cigarettes, in remission F17.211 Screening respiratory tuberculosis Z11.1 Cigarettes, in withdrawal F17. 213 Syncope R55 Other tobacco product, uncomplicated F17.290 Foreign Body 7th character: A=initial, D= FU, S=sequela Other tobacco product, in remission F17.291 Nostril T17.1XX- Other tobacco product, in withdrawal F17.293 Ear; RIGHT T16.1XX- Tobacco use, (no documentation of dependence) avoid Z72.0 LEFT T16.2XX- Occupational exposure to tobacco smoke Z57.31 Underdosing by Patient Code drug from T36-T50 History of nicotine dependence Z87.891 intentional NEC Z91.128 Dermatology due to financial hardship Z91.120 Acne L70.8 unintentional NEC Z91.138 Eczema L30.9 Adverse Effect: Assign additional drug code from T36-T50 Impetigo L01.00 7th character: A=initial, D= FU, S=sequela LICE; Head B85.0 Adverse effect of penicillin T36.0X5- Body B85.1 Misc Rash R21 Zika virus A92.5 Plantar wart B07.0 Sunburn; First degree L55.0 Second degree L55.1 Urticaria L50.9

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 20, 2017 15 INJURY DX CODE SHEET UPPER EXTREMITY RIGHT LEFT LOWER EXTREMITY RIGHT LEFT SHOULDER/HUMERUS: Replace dash with 7th character EOC; KNEE - Replace dash with 7th character EOC; A=Initial D=FU & S=Sequela RIGHT LEFT A=Initial D=FU & S=Sequela RIGHT LEFT Contusion: shoulder S40.011- S40.012- Contusion of the knee S80.01X- S80.02X- Upper arm S40.021- S40.022- Pain M25.561 M25.562 Pain in shoulder M25.511 M25.512 Stiffness M25.661 M25.662 Stiffness, shoulder M25.611 M25.612 Sprain, CRUCIATE ligament, unspecified S83.501- S83.502- Sprain, rotator cuff S43.421- S43.422- Sprain, LATERAL collateral ligament S83.421- S83.422- Strain, rotator cuff S46.011- S46.012- Sprain, MEDIAL collateral ligament S83.411- S83.412- biceps, long head S46.111- S46.112- Tear, meniscus, undescribed S83.206- S83.207- Swelling (disorder, soft tissue) M79.9 M79.9 Subluxation, lateral patella S83.011- S83.012- Joint effusion, shoulder M25.411 M25.412 Joint effusion knee M25.461 M25.462 Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC Swelling - soft tissue disorder M79.9 M79.9 Dislocation shoulder [more detail available] S43.004- S43.005- Laceration, knee, without foreign body S81.011- S81.012- Recurrent dislocation shoulder M24.411 M24.412 Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC ELBOW REGION - Replace dash with 7th character EOC Patella fx S82.001- S82.002- A=Initial D=FU & S=Sequela ANKLE - Replace dash with 7th character EOC; Contusion S50.01X- S50.02X- A=Initial D=FU & S=Sequela Pain M25.521 M25.522 Contusion S90.01X- S90.02X- Stiffness M25.621 M25.622 Pain M25.571 M25.572 Sprain, elbow [more detail available] S53.401- S53.402- Stiffness M25.671 M25.672 Swelling (soft tissue) M79.9 M79.9 Sprain; deltoid ligament S93.421- S93.422- Elbow joint effusion M25.421 M25.422 calcaneofibular ligament S93.411- S93.412- Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC tibiofibular ligament S93.431- S93.432- Nursemaid elbow S53.031- S53.032- other specified ligament (eg., talofibular) S93.491- S93.492- WRIST REGION - Replace dash with 7th character EOC; Joint effusion, ankle M25.471 M25.472 A=Initial D=FU & S=Sequela Swelling (soft tissue) M79.9 M79.9 Contusion S60.211- S60.212- Burn, calf, second degree T24.231- T24.232- Pain M25.531 M25.532 Laceration, ankle, without foreign body S91.011- S91.012- Stiffness M25.631 M25.632 Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC Sprain, wrist [more detail available] S63.501- S63.502- Dislocation S93.04X- S93.05X- Swelling (soft tissue) M79.9 M79.9 FOOT/TOES - Replace dash with 7th character EOC; Wrist joint effusion M25.431 M25.432 A=Initial D=FU & S=Sequela Carpal tunnel syndrome G56.01 G56.02 Contusion S90.31X- S90.32X- Ganglion cyst M67.431 M67.432 Pain M25.571 M25.572 Laceration, forearm, without foreign body S51.811- S51.812- Stiffness M25.674 M25.675 Burn, forearm, second degree T22.211- T22.212- Sprain [more detail available] S93.601- S93.602- Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC Joint effusion, foot M25.474 M25.475 Fx: distal radius, non-displaced S52.501- S52.502- Swelling, skin and subcutaneous tissue R22.41 R22.42 Fx: Colles' S52.531- S52.532- Laceration, foot, without foreign body S91.311- S91.312- HAND - Replace dash with 7th character EOC; Laceration, foot, with foreign body S91.321- S91.322- A=Initial D=FU & S=Sequela Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC Contusion S60.221- S60.222- FX great toe, displaced, unspec phalanx S92.401- S92.402- Pain M79.641 M79.642 FX, lesser toe, displaced, unspec phalanx S92.501- S92.502- Pain in finger(s) M79.644 M79.645 FX, 1st metatarsal, displaced S92.311- S92.312- Stiffness M25.641 M25.642 Sprain unspecified part(s) hand S63.91X- S63.92X- Sprain finger, unspecified finger/region S63.619- S63.619- Hand joint effusion M25.441 M25.442 Burn, palm, second degree T23.251- T23.252- Burn, palm, third degree T23.351- T23.352- Laceration, hand, without foreign body S61.411- S61.412- Laceration, thumb, without foreign body S61.011- S61.012- Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC FX 5th metacarpal shaft, nondisplaced, S62.356- S62.357- FX navicular, w/o specificity [many choices] S62.001- S62.002- FX phalanx, index, nondisplaced S62.600- S62.601- Joint effusion, hand M25.441 M25.442 Joint (wrist) effusion M25.431 M25.432

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 20, 2017 16 INJURY DX CODE SHEET CERVICAL SPINE - Replace dash with 7th character EOC; LACERATIONS A=Initial D=FU & S=Sequela Code Lacerations: Generally right/left specific, with or w/o foreign body. Fingers are Contusion S10.93X- specific, e.g. index, little, middle, ring; thumb has it's own section. All with or w/o Pain - Cervicalgia M54.2 nail damage. Stiffness M43.6 Replace dash with 7th character EOC; Sprain cervical ligament(s) S13.4XX- A=Initial D=FU & S=Sequela RIGHT LEFT Strain muscles, fascia and tendons neck S16.1XX- foot, except toes: S91.311- S91.312- Swelling, skin and subcutaneous tissue R22.1 with foreign body S91.321- S91.322- Injury (undefined) avoid S19.9XX- forehead S01.81X- Radiculopathy M54.12 with foreign body S01.82X- LUMBAR SPINE - Replace dash with 7th character EOC eyelid w/o foreign body S01.111- S01.112- A=Initial D=FU & S=Sequela ear S09.91X- Contusion S30.0XX- scalp w/o foreign body S01.01X- Pain, low back, w/sciatica, right side M54.41 with foreign body S01.02X- Pain, low back, w/sciatica, left side M54.42 face, unsp S09.93X- Pain, low back, without sciatica M54.5 hand S61.411- S61.412- Sprain ligament(s) S33.5XX- with foreign body S61.421- S61.422- Strain muscles, fascia, tendons, low back S39.012- knee S81.011- S81.012- Swelling, soft tissue M79.9 with foreign body S81.021- S81.022- Fx, vertebra due to osteoporosis (HCC= A only) M80.08X- thumb S61.011- S61.012- Radiculopathy, lumbar M54.16 with foreign body S61.021- S61.022- lumbosacral M54.17 with damage to nail S61.111- S61.112- Burn, lower back, second degree T21.24X- with foreign body and nail damage S61.121- S61.122- PELVIS & FEMUR - Replace dash with 7th character EOC OTHER MISCELLANEOUS INJURIES A=Initial D=FU & S=Sequela RIGHT LEFT Black Eye NOS S00.11X- S00.12X- Contusion, pelvis S30.0XX- S30.0XX- Foreign body Contusion, thigh S70.11X- S70.12X- eye T15.91X- T15.92X- Pain, thigh M79.651 M79.652 ear T16.1XX- T16.2XX- Strain, thigh [more detail available] S76.911- S76.912- nose T17.-XX- Strain, hip S76.011- S76.012- pharynx T17.2 - - - Burn, thigh, second degree T24.211- T24.212- Frostbite Sprain, hip [more detail available] S73.101- S73.102- face T33.0 - - - Effusion, hip M25.451 M25.452 hand T33.5 - - - Fractures EMR Search: FX, L/R bone, closed, nondisplaced & EOC foot T33.8 - - - Burns: EMR Search: burn, second degree, right palm & EOC Heatstroke T67.0XX- Second degree palm; initial eval. T23.251- T23.252- Disruption of wound Code also percent of body surface burned Code Also internal surgical wound T81.32X- Less than 10% of body surface burned T31.0 external surgical wound T81.31X- 10% - 19% of body surface burned T31.10 PHYSICAL ABUSE DIAGNOSIS CODES - Replace dash 20% - 29% of body surface burned, add T31.20 with 7th character EOC; A=Initial D=FU & S=Sequela NICOTINE DEPEND vs TOBACCO USE & EXPOSURE Suspected abuse; Cigarette, uncomplicated (no related illness) F17.210 physical abuse of an adult T76.11xX in remission F17.211 sexual abuse of adult T76.21xX in withdrawal F17.213 physical abuse of a child T76.12xX Vapor or "Other" uncomplicated F17.290 sexual abuse of a child T76.22xX in remission F17.291 Confirmed abuse; in withdrawal F17.293 physical abuse of adult T74.11xX Chewing tobacco, uncomplicated F17.220 sexual abuse of adult T74.21xX in remission F17.221 physical abuse of a child T74.12xX in withdrawal F17.223 sexual abuse of a child T74.22xX 2nd hand tobacco smoke exposure Z77.22 Occupational tobacco smoke expos. Z57.31 History of nicotine dependence Z87.891 Tobacco use, [no dependence] avoid Z72.0

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 20, 2017 17 PSYCHIATRIC DX CODE SHEET ADHD - Features are predominately…(choose) Code Major Depressive Disorders (MDD) Code ADHD; inattentive type F90.0 MDD, single episode code choices ADHD; hyperactive type F90.1 "Single episode" is the first-ever episode. DSM-5, pg 162: Dx code for MDD based on ADHD; combined (inattentive and hyperactive types) F90.2 single vs recurrent and severity. ADHD; other type, which is not considered as above three types F90.8 MDD, single episode; (The patient's 1st Dx of MDD - may last months/years) Anxiety and Related Dxs F40 F41 F43 and F93? MDD, single episode; mild severity HCC 58 F32.0 Anxiety; generalized F41.1 MDD, single episode, moderate severity HCC 58 F32.1 Anxiety, mixed (with prominent features of other disorder ) F41.3 MDD, single; severe, WITHOUT psychotic symptoms HCC 58 F32.2 Panic disorder; w/o agoraphobia (panic attack) DEF in note F41.0 MDD, single; severe, WITH psychotic symptoms HCC 58 F32.3 with agoraphobia F40.01 MDD, single episode; in PARTIAL remission HCC 58 F32.4 Separation anxiety (of childhood ) F93.0 MDD, single episode; in FULL remission HCC 58 F32.5 Other specified anxiety disorder (doc in record, but no code) F41.8 MDD, single episode; severity cannot be specified avoid No F32.9 Social phobia (anxiety) disorder, generalized F40.11 MDD, recurrent episode code choices (more common than single episode) Acute stress reaction F43.0 An "episode" likely to last many mos/years. DSM-5, pg 162: "recurrent" = interval of ≥ 2 Post-traumatic Stress Disorder consecutive months between separate episodes in which criteria for MDD are not met. PTSD; acute F43.11 MDD, recurrent episode; mild HCC 58 F33.0 PTSD; chronic F43.12 MDD, recurrent episode; & moderate severity HCC 58 F33.1 Anxiety; unspecified avoid F41.9 MDD, recurrent; severe, WITHOUT psychotic symptoms HCC 58 F33.2 Adjustment Disorders F43.2 MDD, recurrent; severe, WITH psychotic symptoms HCC 58 F33.3 Adjustment disorder; with depressed mood (grief reaction) F43.21 MDD, recurrent episode in PARTIAL remission HCC 58 F33.41 with anxiety F43.22 MDD, recurrent episode in FULL remission HCC 58 F33.42 with mixed mood (anxiety & depression) F43.23 MDD, other reccurrent depressive disorder (specified) HCC 58 F33.8 with disturbance of conduct F43.24 MDD, recurrent episode, unspecified avoid HCC 58 F33.9 with mixed disturbance (emotion/conduct) F43.25 Other Depressive Episodes (Added 2016) with other symptoms not noted in available codes F43.29  Premenstrual dysphoric disorder No F32.81 Adjustment disorder unspecified avoid F43.20  Other specified depressive episode (specified in record) No F32.89 Bipolar Disorders F31 Obsessive-compulsive disorder (OCD) F42 Consider: manic, depressed or mixed, & mild, moderate or severe.  Mixed obsession thoughts and acts F42.2 If "severe" select code based on presence/absence of psychosis.  Hoarding disorder F42.3 Bipolar, current episode is manic & mild HCC 58 F31.11  Excoriation (skin-picking) disorder F42.4 Bipolar; current episode is; manic & moderate HCC 58 F31.12  Other obsessive-compulsive dis. (documented, but not listed above) F42.8 manic & severe WITHOUT psychotic features HCC 58 F31.13  Obsessive-compulsive disorder, unspecified avoid F42.9 manic & severe and WITH psychotic features HCC 58 F31.2 Persistent mood (affective) disorders F34 Bipolar, current episode depressed & mild HCC 58 F31.31 Cyclothymic disorder F34.0 current episode depressed & moderate HCC 58 F31.32 Dysthymic disorder DSM5 = persistent depressive disorder F34.1 depressed but WITHOUT psychotic features HCC 58 F31.4  Disruptive mood dysregulation disorder HCC 58 F34.81 depressed and WITH psychotic features HCC 58 F31.5  Other specified persistent mood disorder HCC 58 F34.89 Bipolar, current episode mixed (manic & dep.) mild HCC 58 F31.61 Mood disorder, unspec. (Active psychosis NOS) avoid HCC 58 F39 Bipolar; current episode mixed & moderate HCC 58 F31.62 Personality Disorders F60 mixed & severe, WITHOUT psychotic features HCC 58 F31.63 Antisocial F60.2 mixed & severe, and WITH psychotic features HCC 58 F31.64 Avoidant F60.6 Bipolar, current episode hypomanic HCC 58 F31.0 Borderline F60.3 Bipolar Disorders IN REMISSION (Partial or Full Remission) Dependent F60.7 Bipolar PARTIAL remission Bipolar FULL remission Histrionic F60.4 hypomanic HCC 58 F31.71 hypomanic HCC 58 F31.72 Narcissistic F60.81 manic HCC 58 F31.73 manic HCC 58 F31.74 Obsessive-compulsive F60.5 depressed HCC 58 F31.75 depressed HCC 58 F31.76 Paranoid F60.0 mixed HCC 58 F31.77 mixed HCC 58 F31.78 Schizoid F60.1 Bipolar disorder, unspecified avoid HCC 58 F31.9 Schizophrenia/Schizoaffective Bipolar II disorder HCC 58 F31.81 Paranoid HCC 57 F20.0 Manic Episode F30 Disorganized HCC 57 F20.1 Manic episode w/o psychotic symptoms mild HCC 58 F30.11 Catatonic HCC 57 F20.2 Manic episode w/o psychotic symptoms moderate HCC 58 F30.12 Undifferentiated HCC 57 F20.3 Manic episode w/o psychotic symptoms severe HCC 58 F30.13 Residual HCC 57 F20.5 Manic episode with psychotic symptoms severe HCC 58 F30.2 Schizophreniform disorder HCC 57 F20.81 Other manic episodes (like hypomania) HCC 58 F30.8 Schizophrenia (a documented but no code exists) HCC 57 F20.89 Manic episode in PARTIAL remission HCC 58 F30.3 Schizoaffective disorder, bipolar type HCC 57 F25.0 Manic episode in FULL remission HCC 58 F30.4 depressive type HCC 57 F25.1 Manic episode, unspecified avoid HCC 58 F30.9 other specified (documented type, not bipolar or depressive) HCC 57 F25.8 Schizoaffective disorder, unspecified avoid HCC 57 F25.9 Screening for Mental Health and Behavioral Disorders Factitious Disorders ● Screening; mental health & behavioral disorders, unspec Z13.30 Δ Factitious disorder imposed on self; unspecified F68.10 ● depression Z13.31 Δ with predominantly psychological sgns and symptoms F68.11 ● maternal depression Z13.32 Δ with predominantly physical sgns and symptoms F68.12 ● other mental health and behavioral disorders Z13.39 Δ with combined psychological physical sgns and symptoms F68.13 ● autism Z13.41 ● Factitious disorder imposed on another F68.A

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 18 PSYCHIATRIC DX CODE SHEET CHILD MALTREATMENT ADULT MALTREATMENT Replace dash with A -initial, D -FU or S -sequela Code Replace dash with A -initial, D -FU or S -sequela Code Child physical abuse, confirmed T74.12X - Adult physical abuse, confirmed T74.11X - Δ Psychological abuse, confirmed T74.32X - Δ Psychological abuse, confirmed T74.31X - Sexual abuse, confirmed T74.22X - sexual T74.21X - Child neglect T74.02X - other abuse and neglect T74.01X - Shaken infant syndrome T74.4XX - Adult neglect (nutritional) T74.01X - ● Sexual exploitation, confirmed T74.52X- ● Sexual exploitation, confirmed T74.51X- ● Sexual exploitation, suspected T76.52X- ● Sexual exploitation, suspected T76.51X- ● Labor exploitation, confirmed T74.62X- ● Labor exploitation, confirmed T74.61X- ● Labor exploitation, suspected T76.62X- ● Labor exploitation, suspected T76.61X- Other Child Dxs Adult Related Info Dx Codes Autistic disorder F84.0 Perpetrator of spousal/partner abuse Z69.12 Heller's syndrome F84.3 Parent child problems, unspecified. Z71.89 Child psychosis NOS F84.9 Perpetrator of parental child abuse Z69.011 Schizophrenia, childhood type F84.5 Parent-biological child problem Z71.89 Child Conduct Disorders Counseling: parent-adopted child problem Z71.89 Oppositional defiant disorder F91.3 Counseling: parent-foster child problem Z71.89 Adolescent onset type F91.2 Parental overprotection Z62.1 Childhood onset type F91.1 Problems with aged parents or in-laws Z63.79 Other conduct disorders F91.8 Alcoholism in family Z63.72 Unspecified F91.9 Substance abuse in family Z63.72 Disorder - Social Functioning Child/Adolescence Personal current military deployment Z65.8 Selective mutism F94.0 Personal Hx return from military deploy Z65.5 Reactive attachment disorder F94.1 Occupational concerns, loss of job Z56.0 Disinhibited attachment disorder F94.2 Change of job Z56.1 Other childhood disorder F94.8 Threat of loss of job Z56.2 Child - Additional Social Status Dxs Stressful work schedule Z56.3 Parent child problems, unspecified. Z71.89 Discord with boss and workmates Z56.4 Parent-biological child problem Z71.89 Difficult conditions at work Z56.5 Counseling-parent-adopted child problem Z71.89 Other physical and mental strain Z56.6 Counseling-parent-foster child problem Z71.89 Social maladjustment Z60.3 Other parent-child problems Z62.820 Legal circumstances Z65.3 Other specific problem related to upbringing Z62.898 Refusal of tx for religious reasons Z53.1 Alcoholism in family Z63.72 Bereavement (disappearance/death) Z63.4 Substance abuse in family Z63.72 Religious or spiritual problem Z65.8 Other psychosocial circumstances Z65.8 Life circumstance problem Z65.8 Social maladjustment Z60.3 Person awaiting admission to facility Z75.0 Legal circumstances Z65.3 Exploitation Dx Codes (Any age) Refusal of tx for religious reasons Z53.1 ● Exam and observation; following forced sexual exploitation Z04.81 Relational problem, NOS Z65.8 ● following forced labor exploitation Z04.82 Bereavement, uncomplicated Z63.4 ● Forced labor or sexual exploitation in childhood Z62.813 Counseling perpetrator of physical/sexual abuse Z69.021 ● Forced labor or sexual exploitation Z91.42 Religious or spiritual problem Z65.8 Emotional State Dx Codes (Any age) Life circumstance problem Z65.8 Nervousness R45.0 Personal History of Mental Disorders (Any age) Irritability & Anger R45.4 Affective disorders Z86.59 Impulsiveness R45.87 Neurosis Z86.59 Emotional Liability R45.86 Alcoholism HCC 55 F10.21 Demoralization/Apathy R45.3 Combat and operational stress Z86.51 Other emotional state R45.89 Other mental disorders Z86.59 Cognitive Defects (Any age) Unspecified mental disorder avoid Z86.59 Attention/concentration R41.840 Family hx of psychiatric condition Z81.8 Cognitive communication R41.841 Other/Miscellaneous Dxs (Any Age) Visuospatial R41.842 Insomnia G47.00 Psychomotor R41.843 Hypersomnia Several codes available Check F51.0 - F51.9 F51.11 Frontal lobe/executive function R41.844 Self mutilation (personal hx) Z91.5 Other cognitive deficits R41.89 Noncompliance Z91.19 Dementia in disease classified elsewhere F02.80 Anorexia nervosa F50.00 Code first, underlying condition code first Bulimia nervosa F50.2 with behavioral disturbances F02.81 Intellectual Disabilities; mild F70 (OB) Puerperium Mental & Behavioral Disorders moderate F71 ● Postpartum depression F53.0 severe F72 ● Peurperal psychosis F53.1 profound F73

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 19 PSYCHIATRIC DX CODE SHEET Signs and Symptoms (Any age) Code Dx - Medication Management Code also clinical condition(s) Code Memory loss R41.3 Code: Therapeutic drug level monitoring Z51.81 Excessive crying R45.83 Code + Long term (current) drug therapy Z79.899 Altered mental status R41.82 Code + Long term (current) use of opiate analgesic Z79.891 Other general symptoms R68.89 Code also the medical/psych diagnosis(es) See code Lack of coordination R27.9 Underdosing of Prescribed Medication by Patient (requires 2 codes) Abnormal weight gain R63.5 Refer these cases to coder for code assignment Abnormal weight loss R63.4 Code first, underdosing of medication (T36-T50) with fifth or sixth character of "6", then Other speech disturbance R47.89 code intent and reason (below) Senility w/o mention psychosis R41.81 1. Look up med or med class in ICD TXX.XXX - Headache R51 When assigning the "T" code, the 7th character will be; Sleep disturbance G47.9 "A" Initial eval of this med management, "D" FU or "S" Sequala Hallucinations R44.3 Patient Medication Noncompliance by Self Underdosing of; Dizziness/giddiness R42 Replace dash (-) w/ A =initial (active tx); D = FU (healing); or S =sequela Decreased libido R68.82 tetracyclic antidepressants T43.026 - Fatigue R53.83 tricyclic antidepressants T43.016 - Generalized pain R52 other antidepressant T43.296 - Night terrors (child) F51.4 antipsychotics (phenothiazine) T43.3x6 - Nicotine Dependence vs Tobacco Use and Exposure amphetamines T43.626 - Cigarette, uncomplicated (no related illness) F17.210 other psychostimulant T43.696 - in remission F17.211 antipsychotics and neuroleptics T43.596 - in withdrawal F17.213 barbiturates T42.3x6 - Vapor or "Other" uncomplicated F17.290 benzodiazepines T42.4x6 - in remission F17.291 butyrophenone/thiothixene narcoleptics T43.4x6 - in withdrawal F17.293 cannabis T40.7x6 - Chewing tobacco, uncomplicated F17.220 MAOIs T43.1x6 - in remission F17.221 methadone T40.3x6 - in withdrawal F17.223 methyphenidate (ADD) T43.636 - 2nd hand tobacco smoke exposure Z77.22 narcotics (synthetic) T40.4x6 - Occupational tobacco smoke exposure Z57.31 opium T40.0x6 - History of tobacco dependence Z87.891 other opioid T40.2x6 - Tobacco use, [no dependence] avoid Z72.0 psychotropic (other) T43.8x6 - "PROVISIONAL DX" / "RULE OUT DX" TODAY?? SSRIs T43.226 - ICD-10 Guidelines prohibit assignment of a diagnosis when that Dx. is only being 2. Code also intent and reason from self underdosing "considered" at this time. One might consider assignment of R69 in cases where INTENTIONAL underdosing of med(s) by patient; a definitive diagnosis cannot yet be assigned. R69 May or may not represent due to financial hardship Z91.120 reimbursement problems, Coder/biller should monitor. for any other reason Z91.128 Mental illness, NOS F99 UNINTENTIONAL underdosing by patient; Illness, unspecified R69 due to age-related debility Z91.130 for any other reason Z91.138 Other Patient Noncompliance Diagnoses Other med. noncompliance (e.g., self overdosing) Z91.14 Noncompliance involving other than medication Z91.19 Noncompliance with diet Z91.11 Social Determinates Illiteracy and low-level literacy Z55.0 Foster care (status) Z62.21 Underachievement in school Z55.3 Family disrupt; due to military deployment Z63.31 Edu. maladjustment, discord w/teachers & classmates Edu.Z55.4 maladjustment,due to other discord absence w/teachers of family & member classmates Z63.32 Unemployment, unspecified Z56.0 due to divorce/legal separation Z63.5 Change of job Z56.1 due to return from military deployment Z63.71 Threat of job loss Z56.2 Problem related to primary support group, unspecified Z63.9 Discord with boss and workmates Z56.4 Conviction civil/criminal proceedings w/o imprisonment Z65.0 Other physical and mental strain related to work Z56.6 Imprisonment and other incarceration Z65.1 Homelessness Z59.0 Lack of physical exercise Z72.3 Inadequate housing Z59.1 Inappropriate diet and eating habits Z72.4 Person living in residential institution Z59.3 Burn-out Z73.0 Lack of adequate food and safe drinking water Z56.4 Type A behavoir pattern Z73.1 Extreme poverty Z59.5 Stress, not elsewhere classified Z73.3 Insufficient social insurance and welfare support Z59.7 Inadequate social skills, not elsewhere classified Z73.4 Other housing/economic circumstance Z59.8 Social role conflict, not elsewhere classified Z73.5 Problems related to living alone Z60.2 Limitation of activites due to disability Z73.6 Acculturation difficulty Z60.3 No household member to render care Z74.2 Social exclusion and rejection Z60.4 Holiday relief care Z75.5 Other problems related to social environment Z60.8 Personal history of adult physical and sexual abuse Z91.410

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 20 CHRONIC PAIN AND SUBSTANCE ABUSE DX CODE SHEET Chronic Pain & Medication Management Code Cannabis Dependence (DSM "moderate / severe") Code Coding chronic pain management: List 1st the chronic pain Dx, then the clinical reason Dx, Cannabis dependence; uncomplicated HCC 55 F12.20 followed by "Therapeutic monitoring" Dx, and finally High-risk medication Dx, if appropriate. Cannabis dependence; in remission HCC 55 F12.21 See 1-4 below. ● Cannabis dependence; with withdrawal F12.23 1. Chronic Pain Syndrome G89.4 with cannabis-induced; with anxiety disorder HCC 55 F12.280 Chronic Pain, unspecified G89.29 with psychotic disorder with delusions HCC 54 F12.250 due to; trauma G89.21 with psychotic disorder with hallucinations HCC 54 F12.251 neoplasm related G89.3 Cannabis dependence with intoxication; uncomplicatedHCC 55 F12.220 2. Common conditions causing chronic pain with delirium HCC 55 F12.221 Arthropathy M12.9 with perceptual disturbance HCC 55 F12.222 Fibromyalgia M79.7 Cannabis Use (w/o abuse or dependence) & Cannabis Poisoning Lumbago M54.5 Cannabis use, unspecified & uncomplicated F12.90 Rheumatoid arthritis HCC 40 M06.9 See F12.9x for other cannabis "use" diagnoses Pain disorder with related psychological factors F45.42 Cannabis poisoning - intent undetermined T40.7x4 - Medication Management (detailed documentation) Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela 3. Therapeutic drug monitoring (code also #4 and/or #5) Z51.81 Cocaine Abuse ("mild") See DSM5 pg. 561 4. ✚ Long term (current) use of opiate analgesic Z79.891 Cocaine abuse; uncomplicated F14.10 5. ✚ Other long term (current) drug therapy Z79.899 Cocaine abuse; in remission F14.11 Alcohol Abuse ("mild") See DSM5 pg.490 Cocaine abuse; with other cocaine-induced disorder HCC 55 F14.188 Alcohol abuse; uncomplicated F10.10 with cocaine-induced; with anxiety disorder HCC 55 F14.180 Alcohol abuse; in remission F10.11 with mood disorder HCC 55 F14.14 with alcohol-induced; with anxiety disorder HCC 55 F10.180 with psychotic disorder with delusions HCC 54 F14.150 with mood disorder HCC 55 F10.14 with psychotic disorder with hallucinations HCC 54 F14.151 with psychotic disorder with delusions HCC 54 F10.150 with sexual dysfunction HCC 55 F14.181 with psychotic disorder with hallucinations HCC 54 F10.151 with sleep disorder HCC 55 F14.182 with sexual dysfunction HCC 55 F10.181 Cocaine abuse with intoxication; uncomplicated HCC 55 F14.120 with sleep disorder HCC 55 F10.182 with delirium HCC 55 F14.121 Alcohol abuse with intoxication; uncomplicated (today) HCC 55 F10.120 with perceptual disturbance HCC 55 F14.122 with delirium HCC 55 F10.121 Cocaine Dependence (DSM "moderate / severe") Alcohol Dependence (DSM "moderate / severe") Cocaine dependence; uncomplicated HCC 55 F14.20 Alcohol dependence; uncomplicated HCC 55 F10.20 Cocaine dependence; in remission HCC 55 F14.21 Alcohol dependence; in remission HCC 55 F10.21 with withdrawal; HCC 55 F14.23 with withdrawal; uncomplicated HCC 55 F10.230 with cocaine-induced; with anxiety disorder HCC 55 F14.280 with delirium HCC 54 F10.231 with mood disorder HCC 55 F14.24 with perceptual disturbance HCC 54 F10.232 with psychotic disorder with delusions HCC 54 F14.250 with alcohol-induced; with anxiety disorder HCC 55 F10.280 with psychotic disorder with hallucinations HCC 54 F14.251 with mood disorder HCC 55 F10.24 with sexual dysfunction HCC 55 F14.281 with persisting amnesic disorder HCC 54 F10.26 with sleep disorder HCC 55 F14.282 with persisting dementia HCC 54 F10.27 Cocaine dependence with intoxication; uncomplicated HCC 55 F14.220 with psychotic disorder delusions HCC 54 F10.250 with delirium HCC 55 F14.221 with psychotic disorder hallucinations HCC 54 F10.251 with perceptual disturbances HCC 55 F14.222 with sexual dysfunction HCC 55 F10.281 Cocaine Use (w/o abuse or dependence) & Cocaine Poisoning with sleep disorder HCC 55 F10.282 Cocaine use unspecified & uncomplicated F14.90 Alcohol dependence with intoxication; uncomplicated HCC 55 F10.220 See F14.9x for other cocaine "use" diagnoses with delirium HCC 55 F10.221 Cocaine poisoning -intent undetermined T40.5x4 - Alcohol Use (w/o abuse or dependence) & Alcohol Poisoning Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Alcohol use unspecified with unspecified alcohol-induced disorder Opioid Abuse ("mild") See DSM5 pg. 540 F10.99 See F10.9x for other alcohol "use" diagnoses Opioid abuse; uncomplicated F11.10 Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Opioid abuse; in remission F11.11 Alcohol poisoning - intent undetermined T51.0x4 - with opioid-induced; with mood disorder HCC 55 F11.14 Blood alcohol level codes with psychotic disorder with delusions HCC 54 F11.150 < 20 mg/100 ml Y90.0 100-119 mg Y90.5 with psychotic disorder with hallucinations HCC 54 F11.151 20-39 mg/100 ml Y90.1 120-199 mg Y90.6 with sexual dysfunction HCC 55 F11.181 40-59 mg/100 ml Y90.2 200-239 mg Y90.7 with sleep disorder HCC 55 F11.182 60-79 mg/100 ml Y90.3 240mg or > Y90.8 Opioid abuse with other induced disorder HCC 55 F11.188 80-99 mg/100 ml Y90.4 Level not specified Y90.9 Opioid abuse with intoxication; uncomplicated HCC 55 F11.120 Cannabis Abuse ("mild") See DSM5 pg. 509 with delirium HCC 55 F11.121 Cannabis abuse; uncomplicated F12.10 with perceptual disturbance HCC 55 F11.122 Cannabis abuse; in remission F12.11 Opioid Dependence (DSM "moderate / severe") with cannabis-induced; with anxiety disorder HCC 55 F12.180 Opioid dependence; uncomplicated HCC 55 F11.20 with psychotic disorder with delusions HCC 54 F12.150 Opioid dependence; in remission HCC 55 F11.21 with psychotic disorder with hallucinations HCC 54 F12.151 with withdrawal HCC 55 F11.23 Cannabis abuse with intoxication; uncomplicated HCC 55 F12.120 with opioid-induced; with mood disorder HCC 55 F11.24 with delirium HCC 55 F12.121 with psychotic disorder with delusions HCC 54 F11.250 with perceptual disturbance HCC 55 F12.122 with psychotic disorder with hallucinations HCC 54 F11.251 with sexual dysfunction HCC 55 F11.281 with sleep disorder HCC 55 F11.282

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 21 SUBSTANCE ABUSE DX CODE SHEET Opioid Dependence continued from prev. page Code Psychoactive Use (not abuse) & Poisoning Code Opioid dependence with other induced disorder HCC 55 F11.288 Psychoactive use unspecified & uncomplicated F19.90 Opioid dependence with intoxication; uncomplicated HCC 55 F11.220 See F19.9x for other psychoactive "use" diagnoses with delirium HCC 55 F11.221 Psychoactive poisoning -intent undetermined T43.94x - with perceptual disturbances HCC 55 F11.222 Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Opioid Use (w/o abuse or dependence) & Opioid Poisoning Sedative/hypnotic/anxiolytic Abuse ("mild") See DSM5 pg. 550 Opioid use unspecified & uncomplicated Sedative abuse; uncomplicated F13.10 F11.90 See F11.9x for other opioid "use" diagnoses Sedative, hypnotic or anxiolytic abuse; in remission F13.11 Opioid poisoning - Intent undetermined T40.2x4 - with sedative-induced; with anxiety disorder HCC 55 F13.180 Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela with mood disorder HCC 55 F13.14 Stimulant Abuse ("mild") See DSM5 pg. 561 with psychotic disorder with delusions HCC 54 F13.150 Stimulant abuse; uncomplicated F15.10 with psychotic disorder with hallucinations HCC 54 F13.151 Other stimulant abuse; in remission. F15.11 with sexual dysfunction HCC 55 F13.181 with stimulant induced; with anxiety disorder HCC 55 F15.180 with sleep disorder HCC 55 F13.182 with mood disorder HCC 55 F15.14 Sedative abuse with other induced disorder HCC 55 F13.188 with psychotic disorder with delusions HCC 54 F15.150 Sedative abuse with intoxication; uncomplicated HCC 55 F13.120 with psychotic disorder with hallucinations HCC 54 F15.151 with delirium HCC 55 F13.121 with sexual dysfunction HCC 55 F15.181 Sedative Dependence (DSM "moderate / severe") with sleep disorder HCC 55 F15.182 Sedative dependence; uncomplicated HCC 55 F13.20 Stimulant abuse with intoxication; uncomplicated HCC 55 F15.120 Sedative dependence; in remission HCC 55 F13.21 with delirium HCC 55 F15.121 with withdrawal; uncomplicated HCC 55 F13.230 with perceptual disturbance HCC 55 F15.122 with delirium HCC 54 F13.231 Stimulant Dependence with perceptual disturbance HCC 54 F13.232 Stimulant dependence; uncomplicated HCC 55 F15.20 with sedative-induced; with anxiety disorder HCC 55 F13.280 Stimulant dependence; in remission HCC 55 F15.21 with mood disorder HCC 55 F13.24 with withdrawal HCC 55 F15.23 with persisting amnestic disorder HCC 54 F13.26 with stimulant-induced; anxiety disorder HCC 55 F15.280 with persisting dementia HCC 54 F13.27 with mood disorder HCC 55 F15.24 with psychotic disorder delusions HCC 54 F13.250 with psychotic disorder with delusions HCC 54 F15.250 with psychotic disorder hallucinations HCC 54 F13.251 with psychotic disorder with hallucinations HCC 54 F15.251 with sexual dysfunction HCC 55 F13.281 with sexual dysfunction HCC 55 F15.281 with sleep disorder HCC 55 F13.282 with sleep disorder HCC 55 F15.282 Sedative dependence with other induced disorder HCC 55 F13.288 Stimulant dependence with intoxication; uncomplicated HCC 55 F15.220 Sedative dependence with intoxication; uncomplicated HCC 55 F13.220 with delirium HCC 55 F15.221 with delirium HCC 55 F13.221 with perceptual disturbances HCC 55 F15.222 Sedative Use (w/o abuse or dependence) & Sedative Poisoning Stimulant Use (w/o abuse or dependence) & Stimulant Poisoning Sedative use unspecified & uncomplicated F13.90 Stimulant use unspecified/uncomplicated See F13.9x for other sedative "use" diagnoses F15.90 See F15.9x for other stimulant "use" diagnoses Sedative poisoning - intent undetermined T42.74x - Stimulant poisoning - Intent undetermined T43.604 - Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Hallucinogen Related Abuse ("mild") See DSM5 pg. 520 Psychoactive Abuse ("mild") See DSM5 pg. 577 Hallucinogen abuse; uncomplicated F16.10 Psychoactive abuse; uncomplicated F19.10 Hallucinogen abuse; in remission F16.11 Other psychoactive substance abuse; in remission F19.11 with Hallucinogen-induced; with anxiety disorder HCC 55 F16.180 with psychoactive-induced; anxiety disorder HCC 55 F19.180 with induced mood disorder HCC 55 F16.14 with mood disorder HCC 55 F19.14 with persisting perception disorder (flashbacks) HCC 55 F16.183 with persisting amnestic disorder HCC 54 F19.16 with psychotic disorder with delusions HCC 54 F16.150 with persisting dementia HCC 54 F19.17 with psychotic disorder with hallucinations HCC 54 F16.151 with psychotic disorder with delusions HCC 54 F19.150 Hallucinogen abuse with other induced disorder HCC 55 F16.188 with psychotic disorder with hallucinations HCC 54 F19.151 Hallucinogen abuse with intoxication; uncomplicated HCC 55 F16.120 with sexual dysfunction HCC 55 F19.181 with delirium HCC 55 F16.121 with sleep disorder HCC 55 F19.182 with perceptual disturbance HCC 55 F16.122 Psychoactive abuse with other induced disorder HCC 55 F19.188 Hallucinogen Dependence (DSM "moderate / severe") Psychoactive abuse with intoxication; uncomplicated HCC 55 F19.120 Hallucinogen dependence; uncomplicated HCC 55 F16.20 with delirium HCC 55 F19.121 Hallucinogen dependence; in remission HCC 55 F16.21 with perceptual disturbance HCC 55 F19.122 with Hallucinogen-induced; with anxiety disorder HCC 55 F16.280 Psychoactive Dependence (DSM "moderate / severe") with mood disorder HCC 55 F16.24 Psychoactive dependence; uncomplicated HCC 55 F19.20 with persisting perception disorder (flashbacks) HCC 55 F16.283 Psychoactive dependence; in remission HCC 55 F19.21 with psychotic disorder with delusions HCC 54 F16.250 with withdrawal; uncomplicated HCC 55 F19.230 with psychotic disorder with hallucinations HCC 54 F16.251 with delirium HCC 54 F19.231 Hallucinogen dependence with other induced disorderHCC 55 F16.288 with perceptual disturbance HCC 54 F19.232 Hallucinogen dependence with intoxication; uncomplicatedHCC 55 F16.220 with Psychoactive-induced; with anxiety disorder HCC 55 F19.280 with delirium HCC 55 F16.221 with mood disorder HCC 55 F19.24 Hallucinogen Use (w/o abuse or dependence) & Poisoning with psychotic disorder with delusions HCC 54 F19.250 Hallucinogen use unspecified & uncomplicated F16.90 with psychotic disorder with hallucinations HCC 54 F19.251 See F16.9x for other sedative "use" diagnoses with sexual dysfunction HCC 55 F19.281 Hallucinogen poisoning; intent undetermined T40.904 - with sleep disorder HCC 55 F19.282 Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela Psychoactive dependence with other induced disorder HCC 55 F19.288 Psychoactive dependence with intoxication; uncomp HCC 55 F19.220 with delirium HCC 55 F19.221 with perceptual disturbances HCC 55 F19.222

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 22 SUBSTANCE ABUSE DX CODE SHEET Nicotine Dependence & Exposure See DSM5 pg. 571 Code Substance Abuse In Pregnancy (see ICD Chapter 15) Code Cigarette; uncomplicated (current smoker) (no related illness) F17.210 Use additional code(s) from F10 to identify manifestations of alcohol use in remission F17.211 Alcohol use complicating pregnancy; 1st trimester O99.311 in withdrawal F17.213 2nd trimester O99.312 Vapor or "Other" uncomplicated F17.290 3rd trimester O99.313 in remission F17.291 Use additional code(s) from F11-F16 to identify manifestations of the drug use in withdrawal F17.293 Drug use complicating pregnancy; 1st trimester O99.321 Chewing tobacco, uncomplicated F17.220 2nd trimester O99.322 in remission F17.221 3rd trimester O99.323 in withdrawal F17.223 Use additional code(s) from F17 to identify type of tobacco nicotine dependence 2nd hand tobacco smoke exposure Z77.22 Smoking complicating pregnancy: 1st trimester O99.331 Occupational tobacco smoke exposure Z57.31 2nd trimester O99.332 History of tobacco dependence Z87.891 3rd trimester O99.333 Tobacco use, [no dependence] avoid Z72.0 Miscellaneous and Signs/Symptoms Screening for Noncompliance with medical treatment Z91.19 Alcoholism Abnormal involuntary movements R25.9 Behavioral disorder Abnormal weight gain R63.5 Z13.89 Depression Abnormal weight loss R63.4 Neurologic disorder Underweight R63.6 HIV Z11.4 BMI of 19 or less Z68.1 STD/STI Z11.3 Malnourished; moderate HCC 21 E44.0 HPV Z11.51 Abnormality of gait R26.9 Intellectual disability Z13.4 Altered mental status R41.82 Malnutrition Z13.29 Decreased libido R68.82 Medication Management Code also clinical condition(s) Dizziness/giddiness R42 Code 1st: Therapeutic drug level monitoring Z51.81 Excessive crying R45.83 Code ✚: Other long term (current) drug therapy Z79.899 Fatigue R53.83 Patient Medication Noncompliance by Self Underdosing of; Generalized pain R52 Replace dash (-) w/ A =initial (active tx); D = FU (healing); or S =sequela Headache R51 tetracyclic antidepressants T43.026 - Hepatitis C, chronic HCC 29 B18.2 tricyclic antidepressants T43.016 - Hepatitis C, acute B17.10 other antidepressant T43.296 - Insomnia G47.00 antipsychotics (phenothiazine) T43.3x6 - Memory loss R41.3 amphetamines T43.626 - Nausea R11.0 other psychostimulant T43.696 - Senility w/o mention psychosis R41.81 antipsychotics and neuroleptics T43.596 - Sleep disturbance G47.9 barbiturates T42.3x6 - Lab Studies - Search for additionals in EMR benzodiazepines T42.4x6 - [Urine drug screen] Encounter other specified exam. Z01.89 butyrophenone & thiothixene neuroleptics T43.4x6 - Finding, abnormal substance in urine R82.99 cannabis T40.7x6 - Blood test for alcohol/drugs Code results Z02.83 MAOIs T43.1x6 - Codes for results listed below, assign if known methadone T40.3x6 - Abnormal findings in blood study methyphenidate (ADD) T43.636 - Opiate drug in blood R78.1 narcotics (synthetic) T40.4x6 - Cocaine in blood R78.2 opium T40.0x6 - Hallucinogen in blood R78.3 other opioid T40.2x6 - Psychotropic in blood R78.5 psychotrophic (other) T43.8x6 - Other addictive substance in blood R78.4 SSRIs T43.226 - Other substance in blood R78.9 Code also PATIENT'S INTENT of underdosing Physical Abuse Diagnosis Codes INTENTIONAL underdosing of med(s) by patient; Replace dash (-) with; A=initial (active tx);D= FU (healing); or S=sequela due to financial hardship Z91.120 Suspected abuse; physical abuse/adult T76.11x - for any other reason Z91.128 sexual abuse of adult T76.21x - UNINTENTIONAL underdosing by patient; physical abuse of a child T76.12x - due to age-related debility Z91.130 sexual abuse of a child T76.22x - for any other reason Z91.138 Confirmed abuse; physical abuse/adult T74.11x - Other Patient Noncompliance Diagnoses sexual abuse of adult T74.21x - Other med. noncompliance (e.g., self overdosing) Z91.14 physical abuse of a child T74.12x - Noncompliance with other medical treatment and regimen Z91.19 sexual abuse of a child T74.22x - Patient's noncompliance with dietary regimen Z91.11 Social Issues - Assign as an Additional Dx Code Personal History and Family History Diagnosis Codes Homelessness Z59.0 Personal History of; Alcoholism HCC 55 F10.21 Inadequate housing Z59.1 Combat and operational stress Z86.51 Lack of adequate food and drinking water Z59.4 Other Mental & Behavioral Disorders Z86.59 Extreme poverty Z59.5 Family History of psychiatric condition Z81.8 Low income Z59.6 Family History of substance abuse Z81.4 Insufficient social ins and welfare support Z59.7 Child in welfare custody (foster care) Z62.21 Institutional upbringing Z62.22 Problems in relationship with spouse/partner Z63.0

Brown Consulting Associates, Inc. ICD-10-CM Common Codes - WIP - October 29, 2018 23